Arteriovenous Access Creation Research Articles

Clinical impact of the Kidney Failure Risk Equation for vascular access planning.

Risk-based thresholds for arteriovenous (AV) access creation has been proposed to aid vascular access planning. We aimed to assess the clinical impact of implementing the kidney failure risk equation (KFRE) for vascular access referral. 16,102 nephrology-referred chronic kidney disease (CKD) patients from the Swedish Renal Registry 2008-2018 were included. The KFRE was calculated repeatedly, and the timing was identified for when the KFRE risk exceeded several pre-defined thresholds and/or the estimated glomerular filtration rate <15 ml/min/1.73m2 (eGFR15). To assess the utility of the KFRE/eGFR thresholds, cumulative incidence curves of kidney replacement therapy (KRT) or death, and decision-curve analyses were computed at 6, 12 months, and 2 years. The potential impact of using the different thresholds was illustrated by an example from the Swedish access registry. The 12-month specificity for KRT initiation was highest for KFRE>50% 94.5 (95% Confidence interval [CI] 94.3-94.7), followed by KFRE>40% 90.0 (95% CI 89.7-90.3), while sensitivity was highest for KFRE>30% 79.3 (95% CI 78.2-80.3) and eGFR<15 ml/min/1.73m2 81.2 (95% CI 80.2-82.2). The 2-year positive predictive value was 71.5 (95% CI 70.2-72.8), 61.7 (95% CI 60.4-63.0) and 47.2 (95% CI 46.1-48.3) for KFRE>50%, KFRE>40%, and eGFR<15 respectively. Decision curve analyses suggested the largest net benefit for KFRE>40% over two years and KFRE>50% over 12 months when it is important to avoid the harm of possibly unnecessary surgery. In Sweden, 54% of nephrology-referred patients started hemodialysis in a central venous catheter (CVC) of which only 5% had AV access surgery >6 months before initiation. 60% of the CVC patients exceeded KFRE>40% a median of 0.8 years (interquartile range 0.4-1.5) before KRT initiation. The utility of using KFRE>40% and KFRE>50% is higher compared to the more traditionally used eGFR threshold <15 ml/min/1.73m2 for vascular access planning.

Assessing Time to Removal of Tunneled Dialysis Catheters after Arteriovenous Access Creation

Tunneled dialysis catheters (TDCs) are a temporary bridge until definitive arteriovenous (AV) access is established. Our objective was to evaluate the time to TDC removal in patients who underwent AV access creations with TDCs already in place. A single-center analysis of all AV access creations in patients with TDCs was performed (2014-2020). Primary outcome was time to TDC removal after access creation. There were 364 AV access creations with TDCs in place. The average age was 58years, 44% of patients were female, and 64% were Black. The median time to TDC removal was 113days (range, 22-931days) with 71.4% having a TDC >90days after access creation. Patients with TDC >90days were often older (60 vs. 54.7), had hypertension (98.1% vs. 93.3%), were diabetic (65.4% vs. 47.1%), and had longer average time to maturation (107.1 vs. 55.4days, P<0.001) and first access (114 vs. 59.4days, P<0.001). Multivariable analysis showed that older age was associated with prolonged TDC placement (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P=0.005) and prosthetic graft use was associated with shorter TDC indwelling time (OR 0.09, 95% CI 0.04-0.23, P ≤ 0.001). Kaplan-Meier analysis showed that 87% of TDCs were removed at 1year. The majority of patients with TDCs who underwent AV access creation had prolonged TDC placement. Prosthetic graft use was associated with shorter catheter times. Close follow-up after access placement, improving maturation times, and access type selection should be considered to shortened TDC times.

Characterization of long-term survival in Medicare patients undergoing arteriovenous hemodialysis access

BackgroundPatients undergoing arteriovenous (AV) access creation for hemodialysis often have significant comorbidities. Our goal was to quantify the long-term survival and associated risks factors for long-term mortality in these patients to aid in optimization of goals and expectations. MethodsThe Vascular Implant Surveillance and Interventional Outcomes Network Vascular Quality Initiative Medicare linked data was used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. Because the majority of hemodialysis patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality. ResultsThere were 13,945 AV access patients analyzed including 10,872 (78%) AV fistulas and 3073 (22%) AV grafts. The median age was 67 years and 56% of patients were male. Approximately one-third had a prior AV access and 44.7% had prior tunneled dialysis catheters. Patients receiving an AV fistula, compared with AV grafts, were more often younger, male, White, obese, independently ambulatory, preoperatively living at home, and less often have a prior AV access and tunneled dialysis catheters (P < .05 for all). The 5-year mortality overall was 62.9% with 61.2% for AV fistulas and 68.8% for AV grafts (P < .001). On multivariable analysis for 5 year mortality, nonambulatory status (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.53-1.83; P < .001), lower extremity access (HR, 1.67; 95% CI, 1.35-2.05; P < .001), human immunodeficiency virus or acquired immunodeficiency syndrome (HR, 1.44; 95% CI, 1.13-1.82; P < .001), White race (HR, 1.43; 95% CI, 1.35-1.51; P < .001), congestive heart failure (HR, 1.33; 95% CI, 1.26-1.41; P < .001), chronic obstructive pulmonary disease (HR, 1.23; 95% CI, 1.15-1.31; P < .001), and AV graft placement (HR, 1.12; 95% CI, 1.02-1.23, P = .016) were most associated with poor survival. Factors associated with improved survival were never smoking (HR, .73; 95% CI, 0.67-0.79; P < .001), prior/quit smoking (HR, .78; 95% CI, 0.72-0.84; P < .001), preoperative home living (HR, .75; 95% CI, 0.68-0.83; P < .001), and hypertension (HR, .89; 95% CI, 0.8-0.99; P = .03). ConclusionsLong-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. There are many modifiable risk factors that may improve survival in these patients and give an opportunity for transplantation.

Arteriovenous access creation and hazards of hospitalization and death in patients starting hemodialysis.

Recent evidence suggests overestimation of benefits associated with arteriovenous (AV) fistula versus graft in certain populations. We assessed hazards of all-cause and cause-specific hospitalization and death associated with AV access type in patients who started hemodialysis with a catheter in France, overall and by subgroups of age, sex, and comorbidities. From the REIN Registry, we included patients who initiated hemodialysis with a catheter from 2010 through 2018, and identified first-created fistula or graft through the French national health-administrative database. We used joint frailty models to deal with recurrent hospitalizations and potential informative censoring by death, and inverse probability weighting to account for confounding. From the 18800 patients included (mean age 68±15 years, 35% women), 5% underwent AV graft creation first. Weighted hazard ratio (wHR) of all-cause hospitalization associated with graft was 1.08 (95% CI 1.02 to 1.15), that of vascular access-related hospitalization was 1.43 (95% CI 1.32 to 1.55), and those of cardiovascular- and infection-related hospitalizations were 1.14 (95% CI 1.03 to 1.26) and 1.11 (95% CI 0.97 to 1.28), respectively. Results were consistent for most subgroups, except that the highest hazard of all-cause, cardiovascular-, and infection- related hospitalizations with graft was blunted in patients with comorbidities (i.e. diabetes, wHR 1.01, 95% CI 0.93 -1.10; 1.10, 95% CI 0.96 to 1.26; and 0.94, 95% CI 0.78 to 1.12, respectively). In patients starting hemodialysis with a catheter, AV graft creation is associated with increased hazard of vascular access-related hospitalizations compared to fistula. This may not be the case for death or other causes of hospitalization.

Recent evaluation by nephrologists is associated with decreased incidence of tunneled dialysis catheter being used at the time of first arteriovenous access creation

ObjectiveLate primary care provider (PCP) or nephrologist evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing initial arteriovenous (AV) access creation, we aimed to study the relationship of recent PCP and nephrologist evaluations with perioperative morbidity and mortality. MethodsWe performed a retrospective review of patients from 2014 to 2022 who underwent initial AV access creation at an urban, safety-net hospital. Univariable and multivariable analyses identified associations of PCP and nephrologist evaluations <1 year and <3 months before surgery, respectively, with hemodialysis initiation via tunneled dialysis catheters (TDCs), 90-day readmission, and 90-day mortality. ResultsAmong 558 patients receiving initial AV access, mean age was 59.7 ± 14 years, 59% were female gender, and 60.6% were Black race. Recent PCP and nephrology evaluations occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured statuses were associated with decreased likelihood of PCP evaluation (unemployment: odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77; uninsured status: OR, 0.05; 95% CI, 0.01-0.45) and nephrologist evaluation (unemployment: OR, 0.63; 95% CI, 0.43-0.91; uninsured status: OR, 0.22; 95% CI, 0.06-0.83) (all P < .05). Social support was associated with increased likelihood of PCP evaluation (OR, 1.81; 95% CI, 1.07-3.08) (all P < .05). Hemodialysis was initiated with TDCs in 304 patients (55%). Older age (OR, 0.98; 95% CI, 0.96-0.99), obesity (OR, 0.38; 95% CI, 0.25-0.58), and nephrologist evaluation (OR, 0.12; 95% CI, 0.08-0.19) were independently associated with decreased hemodialysis initiation with TDCs in patients receiving an initial AV access (all P < .05). Ninety-day readmission occurred in 270 cases (48%). Cirrhosis (OR, 2.5; 95% CI, 1.03-6.03; P = .04), coronary artery disease (OR, 2.31; 95% CI, 1.5-3.57), prosthetic AV access (OR, 1.84; 95% CI, 1.04-3.26), and impaired ambulation (OR, 1.75; 95% CI, 1.15-2.66) were independently associated with increased readmission (all P < .05). Older age (OR, 0.98; 95% CI, 0.97-0.99), prior TDC (OR, 0.65; 95% CI, 0.45-0.94), and unemployment (OR, 0.58; 95% CI, 0.39-0.86) were associated with decreased readmission (all P < .05). Ninety-day mortality occurred in 1.6% of patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality. ConclusionsRecent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients undergoing initial AV access creation. Unemployed and uninsured statuses posed barriers to accessing nephrology care.

Functional Impairment is Associated with Poor Long-Term Outcomes after Arteriovenous Access Creation

Functional impairment affects outcomes after a variety of procedures. However, the impact of functional impairment on outcomes of arteriovenous (AV) access creation is unclear. We aimed to evaluate the association of patients' ability to ambulate and perform activities of daily living (ADL) with AV access outcomes. We retrospectively reviewed patients undergoing AV access creation at an urban, safety-net hospital from 2014-2022. We evaluated associations of impaired ambulatory and assisted ADL status with 90-day readmission, 1-year primary patency, and 5-year mortality. Among 689 patients receiving AV access, mean age was 59.6 ± 13.9 years, 59% were male, and 60% were Black. Access types included brachiocephalic (42%), brachiobasilic (26%), radiocephalic (14%), other autogenous (5%) fistulas and prosthetic grafts (13%). Impaired ambulatory status was identified in 35% and assisted ADL status, when assessed, was identified in 21% of patients. Ninety-day readmission was more likely in patients with impaired ambulatory (58% vs. 39%, P<.001) and assisted ADL (56% vs. 41%, P=.004) status. On Kaplan-Meier analysis, 1-year primary patency was lower for patients with impaired ambulatory status (44% ± 3% vs. 29% ± 3%, P=.001), but was not significantly different for patients with assisted ADL status (41% ± 3% vs. 32% ± 5%, P=.12). Five-year survival was lower for patients with impaired ambulatory status (53% ± 5% vs. 74% ± 4%, P<.001), but was not significantly different for patients with assisted ADL status (45% ± 9% vs. 71% ± 4%, P=.1). On multivariable analysis, increased likelihood of 90-day readmission was significantly associated with impaired ambulatory status (OR 2.03, 95% CI 1.4-2.94, P<.001) and assisted ADL status (OR 1.66, 95% CI 1.07-2.57, P=.02). One-year primary patency was not significantly associated with impaired ambulatory (HR 1.25, 95% CI .98-1.6, P = .07) or assisted ADL status (HR 1.13, 95% CI .87-1.48, P=.36). Increased likelihood of 5-year mortality was associated with impaired ambulatory (HR 1.65, 95% CI 1.04-2.62, P=.04) and assisted ADL status (HR 2.63, 95% CI 1.35-5.11, P=.004). Impaired ambulatory and assisted ADL status were associated with increased readmissions and long-term mortality after AV access creation. Approximately half of patients with functional impairment were not alive at 5 years. Setting outcome expectations as well as prospectively examining the impact of physical therapy and visiting nursing services for functionally impaired patients undergoing AV access creation are warranted.

The impact of neighborhood social disadvantage on presentation and management of first-time hemodialysis access surgery patients

ObjectivesThe impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients. MethodsWe identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed. ResultsThere were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis. ConclusionsThe patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.

#6345 HIGH BRACHIAL ARTERY BIFURCATION AND CLINICAL IMPLICATIONS UPON HEMODIALYSIS VASCULAR ACCESS PLANNING

Abstract Background and Aims Preoperative ultrasound mapping provides information about overall vessel, caliber, flow and anatomic variations, useful for hemodialysis (HD) vascular access planning. High bifurcation of the brachial artery (HBBA) is one of such variations, established early upon fetal development. Its implications in arteriovenous HD access creation are fairly unknown. The present work aims to characterize the prevalence and demographic characteristics of patients presenting with HBBA and study its impact upon HD vascular access planning, construction and patency. Method We developed a retrospective study focusing on 457 patients accessed from 2018 to 2021. Demographic data and presence of HBBA were registered as well as vessel diameter and peak systolic velocities (PSV) for brachial and radial arteries. Theoretical feasibility for each specific access (i.e., radiocephalic, brachiocephalic, brachiobasilic and prosthetic fistulae, according to ultrasound evaluation), final choice of access and 30-day patency were also gathered. Categorical variables are presented as frequencies and percentages and continuous variables as means and standard deviations or medians and interquartile ranges, as appropriate. Logistic regressions were adjusted considering sex, race, arm dominance and HBBA as independent variables. Results From a total of 457 patients, 193 (42,2%) were women and 264 (57,8%) were men. Mean age was 65,4 ±15,3 years. 383 (83,8%) were caucasian and 427 (93,4%) were right-handed. High bifurcation of the brachial artery was present on both arms of 6 (1,3%) patients, only one arm on 62 (13,6%) and on none of the remaining 389 (85,1%) patients. We found an association between being non-caucasian and presenting with HBBA (27% vs 12,5%, p-value = 0,01) but not with sex or arm dominance. Considering all patients, female sex was associated with smaller radial artery diameter, (2,0 ± 0,7 mm vs 2,2 ± 0,6 mm, p &amp;lt; 0,01). HBBA was not associated with a significant difference on arterial diameters (adjusted for sex and race) and there were also no significant differences when comparing dominant vs non-dominant arms. We found no association between HBBA and the theoretical feasibility of a raciocephalic fistula but rather with the choice of arteriovenous graft as the only possible access (26,5% vs 19,5%, p-value = 0,044). A total of 379 (77,0%) patients proceeded to vascular access construction: 59 (15,6%) radiocephalic fistulas, 229 (60,4%) brachiocephalic fistulas, 31 (8,2%) brachiobasilic fistulas and 60 (15,8%) arteriovenous grafts were created, with no differences between HBBA and non-HBBA groups. There was, however, an association between non-caucasian patients and the choice for a more proximal access (p = 0,001) as well as the need for surgical or angiographic reintervention within 45 days after access creation (11 (5%) vs 6 (17,6%), p-value = 0,002). Conclusion Our study suggests that presenting with HBBA is not necessarily associated with lower quality vessels and less distal access construction. However, this variation seems to be more frequent among non-caucasians, who appear to receive more proximal accesses, in greater need for early intervention than their counterparts. Further investigation is necessary to understand if apart from diameter or PSV, HBBA could influence other determinants of access placement choice, such as distance from brachial artery to cephalic or basilic vein or risk of distal hypoperfusion syndrome.

#4404 KIDNEY FUNCTION TRAJECTORY BEFORE AND AFTER ARTERIOVENOUS ACCESS CREATION IN PATIENTS WITH PREDIALYSIS CKD

Abstract Background and Aims Timely arteriovenous (AV) access creation in view of starting hemodialysis is challenged by non-linear kidney function decline and the prospect of competing mortality. In addition, some studies have shown slower CKD progression following AV access creation in patients not on dialysis. While pathophysiological mechanisms, such as ischemic preconditioning and improved kidney perfusion, have been put forward to explain the apparent influence of AV access creation on estimated glomerular filtration rate (eGFR) trajectory, it cannot be ruled out that this finding resulted from an artefact induced by the use of models assuming linear (eGFR) decline before and after AV access creation. Our aim was to describe the kinetics of eGFR decline around the period of AV access creation and to identify different trajectory profiles using models relaxing this hypothesis. Method From 2013 through 2016, the CKD-REIN cohort included 3033 patients with CKD stages 3 to 5 from 40 nationally representative outpatient nephrology clinics in France. Participants were followed for 5 years or until initiation of kidney replacement therapy (KRT), death, or loss to follow-up, whichever came first. This study focused on patients who underwent their first AV access creation during follow-up. Linear mixed models with restricted cubic spline functions (two internal knots, one at AV access creation date, the other, one year before) were used to model a potential non-linear eGFR trajectory over time, based on routine labs. Random effects for the intercept and the spline function components allowed us to deal with individual variations in eGFR trajectory. Instantaneous rates of eGFR decline around AV access creation were then extracted. In addition, we performed latent class mixed models (LCMM) to identify distinct eGFR trajectories. Results During a median follow-up of 5.0 years (interquartile range [IQR], 4.6 to 5.2), 415 (14% of the total population) patients underwent a first AV access creation (32% women, 51% with diabetes). The median age at AV access creation was 69 years (IQR, 61 to 76), and the median eGFR, 13 ml/min/1.73 m² (IQR, 11 to 16). The median numbers of eGFR measurements before and after creation were 12 (IQR, 8 to 19) and 3 (IQR, 2 to 6) respectively. The average eGFR decline in the year before and after AV access creation, assuming constant slopes in each period, was 5.2 ml/min/1.73m² (95% confidence interval [CI], 4.8 to 5.5) and 3.4 ml/min/1.73 m² (95% CI, 3.1 to 3.7), respectively, with a mean difference of −1.8 ml/min/1.73m2 (95% CI, −1.4 to −2.1). Analysis of instantaneous rates showed that the slowdown of eGFR decline began 8.3 months on average (95% CI, 7.8 to 8.6) before AV access creation. The LCMM identified two profiles of eGFR trajectories which mostly differed in the rate of eGFR decline (Figure). In both trajectories, the mean time to the slowdown of eGFR decline preceded time of AV access creation, by 9.1 and 7.2 months in the fastest and slowest eGFR decline trajectories, respectively. Conclusion In nondialysis patients, slowdown of kidney function decline appears to occur several months before AV access creation. Our findings do not support a causal biological effect of AV access creation on CKD progression, but favor alternative hypotheses including optimal management before AV access creation, greater inaccuracy in eGFR estimation in advanced CKD due to muscle mass loss, or simply regression to the mean.

Patency of arteriovenous fistulas and grafts for dialysis access: An analysis using the Korean National Health Insurance Service database from 2008 to 2019.

Arteriovenous (AV) access practice and its outcomes vary internationally. To provide a better understanding of the patterns and outcomes of AV access creation, we investigated the patency and risk factors of arteriovenous fistulas (AVFs) and grafts (AVGs) as initial AV access in the Korean adult population using data from the last 10 years. The National Health Insurance Service database was queried retrospectively to identify patients undergoing hemodialysis with AVFs and AVGs as well as their clinical characteristics and outcomes from 2008 to 2019. AV access patency and its associated risk factors were evaluated. During the study period, 64,179 AVFs and 21,857 AVGs were placed. The mean patient age was 62.6 ± 13.6 years (21.5% were ⩾75 years old), and 39.3% patients were women. More than half of the patients underwent AV access creation at tertiary care hospitals. At 1 year, the primary, primary assisted, and secondary patency rates were 62.2%, 80.7%, and 94.2% for AVFs, and 46.0%, 68.4%, and 86.8% for AVGs, respectively. AVG, older age, female sex, diabetes, and creation at general hospitals (vs tertiary hospitals) were associated with decreased patency outcomes (all, p < 0.05). This study using national data showed that three quarters of patients with AV access had AVF and AVF showed superior performance to AVG and identified several patient and center factors related to AV access patency in Korea.

Characterization of Long-term Survival in Medicare Patients Undergoing Arteriovenous Hemodialysis Access

Patients undergoing arteriovenous (AV) access creation for hemodialysis (HD) often have significant comorbidities. Our goal was to quantify the long-term survival and associated risk factors for long-term mortality in these patients to aid in optimization of goals and expectations. The Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Vascular Quality Initiative Medicare–linked data were used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. As the majority of HD patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality. A total of 13,945 AV access patients were analyzed: 10,872 (78%) AV fistulas and 3073 (22%) AV grafts. Patients receiving an AV fistula were more often younger, male, White, obese, independently ambulatory, preoperatively living at home, have fewer comorbidities, and less often have a prior AV access and tunneled dialysis catheters (P < .05 for all). The 5-year mortality overall was 62.9%, with 61.2% for AV fistulas and 68.8% for AV grafts (P < .001). On multivariable analysis, nonambulatory status (hazard ratio [HR]: 1.67, 95% confidence interval [CI]: 1.53-1.83; P < .0001), lower extremity access (HR: 1.67, 95% CI: 1.35-2.05; P < .0001), HIV/AIDS (HR: 1.44, 95% CI: 1.13-1.82; P = .003), White race (HR: 1.43, 95% CI: 1.35-1.51; P < .0001), current smoking (HR: 1.38, 95% CI: 1.27-1.49; P < .0001), congestive heart failure (HR: 1.33, 95% CI: 1.26-1.41; P < .0001), chronic obstructive pulmonary disease (HR: 1.23, 95% CI: 1.15-1.31; P < .0001), and AV graft placement (HR: 1.12, 95% CI: 1.02-1.23; P = .016) were associated with poor survival. Long-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. Further research focusing on modifiable risk factors in this population is warranted.

Recent Evaluation by a Nephrologist Prior to First Arteriovenous Access Creation Is Associated with Less Tunneled Dialysis Catheter Placement

Recent Evaluation by a Nephrologist Prior to First Arteriovenous Access Creation Is Associated with Less Tunneled Dialysis Catheter Placement

Comprehensive Approach to Improve Quality of Life in Hemodialysis Patients by Early Creation of Arteriovenous Access

An arteriovenous fistula (AVF) is the closest to the ideal model of vascular access. Evidence suggests that people who approach end-stage kidney disease may have an arteriovenous fistula surgically created proactively, enabling the elimination of Permcath insertion for dialysis. Consequently, this proactive action will reduce the risk of bacteremia and admissions to inpatient services for this vulnerable population. The current mean waiting time for AVF creation in King Fahd Armed Forces Hospital, Jeddah (KFAFH), was 172 days. The aim of the project was to decrease the adult Chronic Kidney Disease patient mean waiting time for arteriovenous (AV) access creation from a mean of 172 days to less than 10 days within 12 months. The project was carried out in the Chronic Kidney Disease patient population of King Fahd Armed Forces Hospital, Jeddah. The Plan Do Study Act rapid cycles Quality improvement method was used to implement changes. The interventions include a multidisciplinary approach as the base for the new AVF strategy. Identification of CKD Stage IV patients with impending dialysis was booked for early AVF, thereby reducing the need for Permcath. An additional renal clinic was established to update the patients waiting time for AVF creation and to book patients as Day-surgery through fast track. Daily rounds in the dialysis unit were introduced to address issues of new patients on hemodialysis, and the waiting time for each patient was revised and booked to the new renal clinic for AVF creation. This reduced the referral time to the vascular clinic. Centralized approach by requesting early venogram &amp; venous mappings. The addition of a dedicated inpatient bed for advanced access surgery like AV graft, superficialization, and bridging for patients on anti-coagulation was allotted. Addition of a dedicated operating room for at least daily AVF creation apart from the regular operating list. Addition of 1 more day to existing 1 day per week schedule for Day case procedures with 2 day surgery beds for vascular access. During the 1st PDCA cycle, the mean waiting time for AVF Access decreased to 127.75 days; during the 2nd PDCA cycle, the mean time decreased to 34.25 days, and during the 3rd PDCA cycle the project achieved proactive AVF access with the mean waiting time at -7.2 days. None of the patients with newly created AVF access developed steal syndrome during the project period. AV fistulae have a longer median survival, require less costly and invasive intervention to maintain patency and are less likely to become infected than AV graft or Permcath. A multidisciplinary team approach proved to be successful in reducing the mean AVF waiting time for hemodialysis patients. The interventions enable the team to perform proactive AVF creation in a timely manner eliminating the use of Permcaths for newly admitted Hemodialysis patients. Thus, reducing the CLABSI rate.

Functional Impairment Is Associated with Poor Outcomes after Arteriovenous Access Creation

Functional Impairment Is Associated with Poor Outcomes after Arteriovenous Access Creation

Intravenous Heparin During Radiocephalic Arteriovenous Access Creation: A Target Trial Emulation

Intravenous Heparin During Radiocephalic Arteriovenous Access Creation: A Target Trial Emulation

Hemodialysis Arteriovenous Access Cosmesis Scale (AVACS): A new measure for vascular access.

This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials. Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation. The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development. For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%. The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance. Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use. While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis.

Health insurance provider and endovascular treatment availability are associated with different hemodialysis vascular access profiles: A Brazilian national survey.

In Brazil, most hemodialysis (HD) patients are treated by the country's public health system. However, accessibility to healthcare is different for public and private patients. This study aimed to identify the profile of vascular access in a Brazilian HD sample. Additionally, it aimed to examine the influence of public and private health insurance, accessibility to endovascular treatments, and timely arteriovenous access creation on the prevalence of tunneled catheters (TCs), non-tunneled catheters (NTCs), and arteriovenous (AV) access. We conducted a cross-sectional electronic survey across 834 centers. Centers were inquired about the number of patients with public and private health insurance, the profiles of vascular access, time for AV access creation, accessibility to TC insertion and endovascular treatments, and the availability of peritoneal dialysis and kidney transplantation. Logistic regression and multilevel logistic regression were performed to evaluate possible interactions between the independent variables. A total of 7,973 patients across 47 HD centers were included in the survey. Public health patients accounted for 77% of the study sample. The overall vascular access profiles of the public and private insurance groups were significantly different (p<0.001). For patients with public health insurance, the prevalence of any catheter was 25%, while that for private patients was 31.8% (p<0.001). The prevalence of TCs was more common in private patients (15.3% vs. 23.1%, p<0.001). AV accesses were more common in public health patients (75% vs. 68.2%, p<0.001), as were fistulas (72.4% vs. 63.1%, p<0.001). AV grafts were more prevalent among patients with private insurance (2.6 vs. 5.1%, p<0.001). The availability of endovascular treatments increased the chance of having a TC by 2.3-fold (OR=2.33, 95% CI=1.30-4.18); however, it did not reduce the chance of having any catheter. A high chance of having a catheter was found when the time to AV access creation exceeded 60days. The differences between public and private patients may be explained by underpayments and the decreased accessibility to care infrastructure in the public system, especially for endovascular treatments. In this sample, public health patients had a decreased risk of having a TC over an NTC. Differences in care accessibility and insurance type might influence the type of vascular access.

Pharmacological Assistance Therapies for Arteriovenous Access Creation and Intervention for Dialysis Patients

Pharmacological Assistance Therapies for Arteriovenous Access Creation and Intervention for Dialysis Patients

Re-admissions Following Arteriovenous Access: What’s New?

Arteriovenous (AV) access has primary failure rates of up to 46%, according to a recent series,1 with one year patency ranging 52 – 83%. These results mean that re-hospitalisations are often necessary, especially in the first year following AV access creation. The study by Coscas et al.2 underlines this ongoing and recurrent problem through an epidemiological study based on the French National Database. However, it is unsurprising to find a high frequency of re-admissions and re-interventions (i.e., a 63% rate of re-hospitalisation, with 53% of re-operations mainly due to primary failure and early stenosis).

Readmissions Following Arteriovenous Access Creation for Haemodialysis in a French National Database

There is a lack of large real world data on arteriovenous (AV) access results. This study aimed to describe the required hospital care during the first year following creation of AV access. Data from all adult patients who underwent creation of AV access performed in 2017 in a public or private facility were collected through the French national hospitalisation database. Patients were classified into two groups ("de novo" and "secondary") according to their history of prior AV access creation. The primary outcome was the proportion of patients with at least one hospital readmission related to the AV access recorded during the first 12 post-operative months. In 2017, 10 476 adult patients underwent AV access creation in France, including 8 690 (83%) de novo creations. An AV fistula was created for 92% of the patients (95% de novo vs. 78% secondary; p < .001). During the first 12 post-operative months, 6 591 (63%) patients recorded at least one related readmission (68% secondary vs. 62% de novo; p < .001). A total of 5 557 (53%) recorded a readmission for surgical/interventional procedure and 2 852 (27%) were observed with a readmission for medical complications. The mean (± standard deviation) number of related readmissions at 12 months was 1.4 ± 1.6 per patient (1.7 ± 1.9 secondary vs. 1.3 ± 1.5 de novo; p < .001). Patients with an AV graft were more frequently readmitted than those with an AV fistula (1.8 ± 2 vs. 1.3 ± 1.5 readmission; p < .001). This study highlights the high frequency of readmissions during the first 12 months following creation of AV access, particularly in patients who had already undergone creation of a previous AV access or had an AV graft implanted. Further research should focus on tailoring AV access strategies to improve patient quality of life and decrease the healthcare cost burden.