Abstract
BackgroundCreating permanent vascular access (VA) is recommended before hemodialysis initiation in patients with end-stage renal disease (ESRD). Although many patients are still introduced to hemodialysis with temporary central venous catheters (CVCs), the reasons for their use remain unclear. We aimed to clarify the characteristics of Japanese patients introduced to hemodialysis using temporary CVCs, the reasons for their use, and whether this rate can be reduced in the future.MethodsWe conducted this cross-sectional study in an acute care general hospital in Japan. We enrolled 393 patients aged ≥ 18 years who received a permanent VA creation for initiating hemodialysis. We classified participants into the temporary CVC group or the permanent VA group according to the VA type at hemodialysis initiation and compared their backgrounds. We identified why permanent VA could not be used at hemodialysis initiation for patients in the temporary CVC group.ResultsOf the 393 patients, 137 (35%) initiated hemodialysis with a temporary CVC, and arteriovenous fistulas (AVFs) were created as the first VA in all patients during hospitalization following hemodialysis initiation. The remaining 256 patients (65%) initiated hemodialysis via AVF cannulation. The duration of predialysis nephrology care was significantly shorter in the temporary CVC group than that in the permanent VA group. The median time from AVF creation to the first successful cannulation was also shorter in the temporary CVC group (8 vs. 66 days, P < 0.001), but the estimated glomerular filtration rate values at hemodialysis initiation did not differ. Reasons for temporary CVC use were varied and complex. Problems on the part of healthcare providers, patient behavioral issues, and characteristics of causative kidney disease itself were underlying reasons. Delayed referral to a nephrologist was less frequent than expected (16%) and the most commonly reported reason (20%) was that a nephrologist was unable to predict the timing of hemodialysis initiation.ConclusionsPatients with ESRD should be referred to a nephrologist earlier for AVF creation. However, given the already relatively high rate of hemodialysis initiation with permanent VA in Japan, we considered it surprisingly difficult to further reduce the temporary CVC usage rate in Japan.
Highlights
Creating permanent vascular access (VA) is recommended before hemodialysis initiation in patients with end-stage renal disease (ESRD)
An arteriovenous fistula (AVF) was created in all patients in the temporary central venous catheter (CVC) group during hospitalization following HD initiation, and most patients were transferred to a maintenance dialysis facility after their AVF became usable
In the temporary CVC group, 60% of the patients had been treated by a nephrologist for less than 6 months, and only 35% had been treated by a nephrologist for more than 1 year
Summary
Creating permanent vascular access (VA) is recommended before hemodialysis initiation in patients with end-stage renal disease (ESRD). The Japanese Society for Dialysis Therapy (JSDT) clinical guidelines for the construction and repair of VA recommends that the timing of VA creation should be determined based on the clinical symptoms and an estimated glomerular filtration rate (eGFR) of 15 mL/min/1.73 m2 or less. It advises predicting the timing of HD initiation from laboratory data and clinical symptoms and creating an arteriovenous fistula (AVF), which is the most common type of VA, at least 2 to 4 weeks before the initial cannulation [5]. HD initiation with a temporary central venous catheter (CVC) has been reported to have higher costs and longer hospital stays than permanent VA, such as an AVF and arteriovenous graft (AVG) [8]
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