Hemodialysis International 2014; 18:516–521
Improving arteriovenous fistula rate: Effect on hemodialysis quality Ayman KARKAR,1 Ahmed CHABALLOUT,2 Maher Haj IBRAHIM,1 Mohammed ABDELRAHMAN,1 Mona AL SHUBAILI1 1 Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, Dammam, Saudi Arabia; 2Department of Vascular Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Abstract Vascular access (VA) is the lifeline for patients with end-stage renal disease on regular hemodialysis (HD). Tunneled catheters have been associated with increased risk of luminal thrombosis, infection, hospitalization, and high cost. Our aims were to follow the “Fistula First Initiative,” avoid or reduce the rate of catheter insertion, improve the rate of arteriovenous fistula (AVF) use, and study the effect of increased AVF use on quality of dialysis and patient’s outcome. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team to manage 358 patients who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation age of patients was 52 ± 15 years with 62% male patients. Over a period of 2 years, 408 procedures were performed. These include 293 AVFs and 56 arteriovenous grafts (AVGs). Other procedures include 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele, and ligation of 1 AVF. This program resulted in significant increase in AVF rate from 35% to 82%; reduction in catheter rate from 62% to 10.9%; infection rate down from 6.6% to 0.6%; VA clotting down from 5.1% to 1.0%; and increase in average blood flow rate from 214 ± 32 to 298 ± 37 mL/min (P < 0.01). These results have been associated with improved average single pool Kt/V from 0.88 ± 0.19 to 1.28 ± 0.2 (P < 0.01); increased hemoglobin from 9.2 ± 1.2 to 10.9 ± 0.9 g/dL (P < 0.01); improved serum albumin from 3.2 ± 0.5 to 3.7 ± 0.4 g/dL (P < 0.05); reduction in administered erythropoietin dose by 19%; and significant drop in hospitalization rate from 6.1% to 3.8%. These results confirm the great benefits of AVF on quality of HD and patient outcome, and clearly affirm that AVF should always be considered first. Key words: Vascular access, arteriovenous fistula, graft, catheter, hemodialysis, infection
INTRODUCTION Correspondence to: A. Karkar, PhD, FRCP, FASN, Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, PO Box 11825, Dammam 31463, Kingdom of Saudi Arabia. E-mail: [email protected] Conflict of interest: There is no conflict of interest.
Vascular access (VA) is the lifeline for patients with endstage renal disease (ESRD) on regular hemodialysis (HD).1 There are three major types of VA: arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). The type of VA is associated with patient outcome. Tunneled catheters, for example, have been associated with increased risk of luminal thrombosis,
© 2013 International Society for Hemodialysis DOI:10.1111/hdi.12102
516
Improving AVF rate
central venous stenosis, inadequate blood flow rate, inadequate dialysis, increased risk of infection, increased risk of hospitalization, increased risk of death, and high cost.2–5 AVG has also been associated with graft stenosis, fivefold increase in infection risk, poorer long-term patency, and higher levels of complications and interventions.6 The Kidney Disease: Improving Global Outcomes guidelines published in 20017 defined the ideal VA as that which (1) delivers adequate flow rate for the dialysis prescription, (2) has a long use-life, and (3) has a low rate of complications (infection, stenosis, thrombosis, aneurysm, and limb ischemia). Although none of the major types of VA fulfills all of these criteria, the native AVF is the closest to this definition. Achieving high AVF rate among HD patients could be a challenging task. The lack or inadequate predialysis care of patients with ESRD or late referral to a nephrologist8 will expose patients to emergency femoral or jugular catheter insertion because of the lack of time for creation and maturation of an AVF. The decision to insert a temporary VA is also based on poor clinical status of patients and their unsuitability for elective surgery, and/or the refusal of some patients with ESRD to accept surgery during their denial stage. Patients with established subclavian catheters may be at increased risk of losing the chance of having AVF in that arm forever because of subclavian vein stenosis or occlusion. In addition, AVF is not a minor surgery and should be performed by an experienced vascular surgeon after adequate evaluation and preparation, otherwise the chance of failure is high and the patient will lose all access sites within a short period of time following initiation of dialysis. Furthermore, vascular surgeons are usually available only in major centers, and most of them are not interested in access surgery (but in performing aortic and carotid surgery and endovascular procedures). Moreover, failure rate of access surgery is high all over the world, and only dedicated surgeons who are willing to take care of these patients immediately if they lose their access sites can improve the AVF success rate. Even patients with ESRD who are prepared for an AVF creation may lose the saved arm because of repeated blood pressure measurement, needle puncture for blood sampling, or intravenous therapy, which may result in clotting or fibrosis of veins. Finally, created AVF may fail as a result of poor patient/nursing care and/or not checking the high venous flow by a nephrologist and sending the patient for fistulogram and angioplasty before the establishment of thrombosis. In 2002, Pisoni et al. revealed in their DOPPS study the low rate of prevalent (24%) and incident (15%) AVF use among US HD centers.9 These findings were
Hemodialysis International 2014; 18:516–521
followed by the “Fistula First Breakthrough Initiative” (http://www.fistulafirst.org), established in 2003,10 under which a goal was set to have a prevalent AVF use rate of 40% in US patients with HD. This goal was achieved in 2005.11 The bar was subsequently raised to 66% AVF use, a level which was comparable with that achieved in several European countries.12 The current prevalent AVF use rate in the US is about 62%, with incident AVF use rate still below 20%.13 DOPPS 4 of 2010 Study showed Australia, New Zealand and some European countries (France, Italy and Germany) have achieved more than 70% AVF use compared with Japan, which achieved more than 90%. The increased incidence and prevalence of catheterassociated complications among our patients and the progressive increase in number of patients in need of HD in our center and in nearby satellite dialysis units, with more than 400 patients on regular HD and 5 to 10 new patients per week, prompted our team to follow the “Fistula First Initiative”. Accordingly, a vascular surgery program has been established in collaboration with an enthusiastic and professional vascular surgery team. The aims were to increase the AVF rate among our incident and prevalent ESRD/HD patients and other regional satellite HD units, avoid or reduce catheter use and its subsequent complications, and study the effect of increased AVF rate on quality of HD and patient’s outcomes.
METHODS AND RESULTS Our previous process of VA creation was dependent on the only available vascular surgeon consultant who had many commitments especially in the cardiothoracic surgery and accident and emergency departments. Despite his great efforts to contribute in improving AVF rate, it was quite difficult for him to cope with the increasing number of patients with ESRD in need of VA and at the same time to fulfill his commitments. Accordingly, prior arrangements and an agreement had been made with the local vascular surgeon, the surgery department, and the administration before establishing the collaboration and sending invitations to the visiting vascular surgery team. This collaboration was, in fact, part of an already established “outreach program” between hospitals for help and support in different medical and surgical aspects. The logistics of the arrival and departure of the visiting team were taken care of by our coordinator and the public relations department. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team, which was started in July 2010. The visiting
517
Karkar et al.
vascular surgery team consisted of one senior vascular surgeon consultant and two vascular surgery specialists. Our team includes an active coordinator (a nephrologist consultant), one resident from the day surgery department, one resident from the dialysis unit, three nurses from the day surgery department, one nurse from the outpatient department, five nurses from the dialysis room, one echocardiography consultant, one consultant radiologist, and an anesthesia team composed of one consultant, two specialists and four operating room technicians. The collaboration was based on the adequate coordination and preparation of patients with ESRD in need of VA, by our team, for regular visits to the vascular surgery team at our referral kidney center. Initially, the visits were bimonthly, and from December 2011, the visits became on a monthly basis. The program was shifted from admission to day surgery from January 2011. The team used to stay for 1 to 2 days per visit to manage incident (n = 62) and prevalent (n = 195) patients with ESRD in need of HD. All procedures were in accordance with the ethical standards of the committee on human experimentation of our institution. A written informed consent was obtained from each subject. Different measures were taken in our department to improve the predialysis VA placement. This includes the establishment of a “low-clearance” clinic, where patients with stage 4 to 5 chronic renal failure are seen by a renal team (including a nephrologist, dialysis nurse, social worker, and dietician), who introduces the different modalities of renal replacement therapy, including the types of access required (peritoneal catheter or AVF). Furthermore, collaborations have been established with primary health care physicians for the education and early referral of such patients. These efforts have resulted, so far, in creating AVF in 62 incident patients over the course of this study. Our team prepared all patients in need of new VAs and previous complicated VAs before the arrival of the vascular surgery team. All our patients had their echocardiogram done by an echocardiologist consultant at our kidney center. Some patients went through Doppler ultrasound of the upper limbs and neck vessels. Other patients required computed tomography angiogram of neck vessels and superior vena cava. Clinical evaluation, laboratory investigations and HD sessions for all patients were performed one day prior to surgery. Patients who required general anesthesia had undergone full evaluation by our anesthesia team. Patients with ESRD from regional dialysis centers and/or satellite dialysis units were received by our team one day before operation. Clinical evaluation, revision of all investigations and consultations, if required, and
518
HD sessions were performed at our center one day before surgery. Vascular surgery operations were conducted simultaneously in two adjacent operating rooms. On surgery day, patients were received in the reception area of the day surgery unit. Clinical assessment and review of the investigations were rechecked by our staff. Intravenous access and other preoperative preparations were done by the nursing staff, and the patient was sent to the operating room once called. Postoperative patient was received back in the reception area and managed there by our staff. Within a period of 3 to 4 h, patients were ready to be discharged after appropriate evaluation and assessment. Reevaluation and assessment of the AVF was performed 4 to 6 weeks after surgical procedure. All usual nursing care measures were taken post-AVF creation until full maturation took place. Only in minority of the patients, who were either planning for kidney transplantation or where AVF or AVG creation was impossible, as well as those who refused the AVF creation, a permanent catheter was inserted by the vascular surgery team. In other patients, where AVF creation was impossible, AVG creation was done by the same vascular surgery team. On subsequent visits, the team managed to perform other minor procedures such as AVG embolectomy, AVG removal, AVG lymphocele excision, AVF ligation, and AVF aneurysmectomy. The visiting vascular surgery team managed 358 patients (306 patients from our kidney center and 52 patients from other satellite dialysis units), who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation (SD) age of patients was 52 ± 15 years with 62% male patients, including 84 (32.7%) who were diabetic. Over a period of 2 years, there were 15 visits of the vascular surgery team to our kidney center, where 408 procedures were performed with an average of 26 procedures completed per visit (Figure 1). The performed procedures include 293 AVFs, 56 AVGs, 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele and ligation of 1 AVF. There were 66 redos, which accounts for 25.7%. The sites of created AVF were brachiocephalic in 158 patients (56%), brachiobasilic in 26 patients (9%), radiocephalic in 21 patients (7%), and basilic transposition in 24 patients (9%). Based on adequate and maintained blood flow rate and luminal diameter of more than 0.4 cm assessed by ultrasound, the achieved AVF success rate exceeded 90%. The primary failure rate was 7% (18/257) and the late failure rate (after 2 years) was 8% (19/239). The waiting time
Hemodialysis International 2014; 18:516–521
Improving AVF rate
Table 1 Comparison between a group of our patients who previously dialyzed with catheters and patients who enrolled in this study with established and functioning AVF
Infection rate Clotting Blood flow rate Kt/V Hb Serum albumin Hospitalization
Catheter
AVF
P value
(n = 157) 6.1% 5.1% 214 + 32 0.88 + 0.19 9.2 + 1.2 3.2 + 0.5 6.1%
(n = 176) 0.6% 1% 298 + 37 1.28 + 0.2 10.9 + 0.9 3.7 + 0.4 3.8%
Improving arteriovenous fistula rate: Effect on hemodialysis quality Ayman KARKAR,1 Ahmed CHABALLOUT,2 Maher Haj IBRAHIM,1 Mohammed ABDELRAHMAN,1 Mona AL SHUBAILI1 1 Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, Dammam, Saudi Arabia; 2Department of Vascular Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Abstract Vascular access (VA) is the lifeline for patients with end-stage renal disease on regular hemodialysis (HD). Tunneled catheters have been associated with increased risk of luminal thrombosis, infection, hospitalization, and high cost. Our aims were to follow the “Fistula First Initiative,” avoid or reduce the rate of catheter insertion, improve the rate of arteriovenous fistula (AVF) use, and study the effect of increased AVF use on quality of dialysis and patient’s outcome. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team to manage 358 patients who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation age of patients was 52 ± 15 years with 62% male patients. Over a period of 2 years, 408 procedures were performed. These include 293 AVFs and 56 arteriovenous grafts (AVGs). Other procedures include 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele, and ligation of 1 AVF. This program resulted in significant increase in AVF rate from 35% to 82%; reduction in catheter rate from 62% to 10.9%; infection rate down from 6.6% to 0.6%; VA clotting down from 5.1% to 1.0%; and increase in average blood flow rate from 214 ± 32 to 298 ± 37 mL/min (P < 0.01). These results have been associated with improved average single pool Kt/V from 0.88 ± 0.19 to 1.28 ± 0.2 (P < 0.01); increased hemoglobin from 9.2 ± 1.2 to 10.9 ± 0.9 g/dL (P < 0.01); improved serum albumin from 3.2 ± 0.5 to 3.7 ± 0.4 g/dL (P < 0.05); reduction in administered erythropoietin dose by 19%; and significant drop in hospitalization rate from 6.1% to 3.8%. These results confirm the great benefits of AVF on quality of HD and patient outcome, and clearly affirm that AVF should always be considered first. Key words: Vascular access, arteriovenous fistula, graft, catheter, hemodialysis, infection
INTRODUCTION Correspondence to: A. Karkar, PhD, FRCP, FASN, Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, PO Box 11825, Dammam 31463, Kingdom of Saudi Arabia. E-mail: [email protected] Conflict of interest: There is no conflict of interest.
Vascular access (VA) is the lifeline for patients with endstage renal disease (ESRD) on regular hemodialysis (HD).1 There are three major types of VA: arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). The type of VA is associated with patient outcome. Tunneled catheters, for example, have been associated with increased risk of luminal thrombosis,
© 2013 International Society for Hemodialysis DOI:10.1111/hdi.12102
516
Improving AVF rate
central venous stenosis, inadequate blood flow rate, inadequate dialysis, increased risk of infection, increased risk of hospitalization, increased risk of death, and high cost.2–5 AVG has also been associated with graft stenosis, fivefold increase in infection risk, poorer long-term patency, and higher levels of complications and interventions.6 The Kidney Disease: Improving Global Outcomes guidelines published in 20017 defined the ideal VA as that which (1) delivers adequate flow rate for the dialysis prescription, (2) has a long use-life, and (3) has a low rate of complications (infection, stenosis, thrombosis, aneurysm, and limb ischemia). Although none of the major types of VA fulfills all of these criteria, the native AVF is the closest to this definition. Achieving high AVF rate among HD patients could be a challenging task. The lack or inadequate predialysis care of patients with ESRD or late referral to a nephrologist8 will expose patients to emergency femoral or jugular catheter insertion because of the lack of time for creation and maturation of an AVF. The decision to insert a temporary VA is also based on poor clinical status of patients and their unsuitability for elective surgery, and/or the refusal of some patients with ESRD to accept surgery during their denial stage. Patients with established subclavian catheters may be at increased risk of losing the chance of having AVF in that arm forever because of subclavian vein stenosis or occlusion. In addition, AVF is not a minor surgery and should be performed by an experienced vascular surgeon after adequate evaluation and preparation, otherwise the chance of failure is high and the patient will lose all access sites within a short period of time following initiation of dialysis. Furthermore, vascular surgeons are usually available only in major centers, and most of them are not interested in access surgery (but in performing aortic and carotid surgery and endovascular procedures). Moreover, failure rate of access surgery is high all over the world, and only dedicated surgeons who are willing to take care of these patients immediately if they lose their access sites can improve the AVF success rate. Even patients with ESRD who are prepared for an AVF creation may lose the saved arm because of repeated blood pressure measurement, needle puncture for blood sampling, or intravenous therapy, which may result in clotting or fibrosis of veins. Finally, created AVF may fail as a result of poor patient/nursing care and/or not checking the high venous flow by a nephrologist and sending the patient for fistulogram and angioplasty before the establishment of thrombosis. In 2002, Pisoni et al. revealed in their DOPPS study the low rate of prevalent (24%) and incident (15%) AVF use among US HD centers.9 These findings were
Hemodialysis International 2014; 18:516–521
followed by the “Fistula First Breakthrough Initiative” (http://www.fistulafirst.org), established in 2003,10 under which a goal was set to have a prevalent AVF use rate of 40% in US patients with HD. This goal was achieved in 2005.11 The bar was subsequently raised to 66% AVF use, a level which was comparable with that achieved in several European countries.12 The current prevalent AVF use rate in the US is about 62%, with incident AVF use rate still below 20%.13 DOPPS 4 of 2010 Study showed Australia, New Zealand and some European countries (France, Italy and Germany) have achieved more than 70% AVF use compared with Japan, which achieved more than 90%. The increased incidence and prevalence of catheterassociated complications among our patients and the progressive increase in number of patients in need of HD in our center and in nearby satellite dialysis units, with more than 400 patients on regular HD and 5 to 10 new patients per week, prompted our team to follow the “Fistula First Initiative”. Accordingly, a vascular surgery program has been established in collaboration with an enthusiastic and professional vascular surgery team. The aims were to increase the AVF rate among our incident and prevalent ESRD/HD patients and other regional satellite HD units, avoid or reduce catheter use and its subsequent complications, and study the effect of increased AVF rate on quality of HD and patient’s outcomes.
METHODS AND RESULTS Our previous process of VA creation was dependent on the only available vascular surgeon consultant who had many commitments especially in the cardiothoracic surgery and accident and emergency departments. Despite his great efforts to contribute in improving AVF rate, it was quite difficult for him to cope with the increasing number of patients with ESRD in need of VA and at the same time to fulfill his commitments. Accordingly, prior arrangements and an agreement had been made with the local vascular surgeon, the surgery department, and the administration before establishing the collaboration and sending invitations to the visiting vascular surgery team. This collaboration was, in fact, part of an already established “outreach program” between hospitals for help and support in different medical and surgical aspects. The logistics of the arrival and departure of the visiting team were taken care of by our coordinator and the public relations department. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team, which was started in July 2010. The visiting
517
Karkar et al.
vascular surgery team consisted of one senior vascular surgeon consultant and two vascular surgery specialists. Our team includes an active coordinator (a nephrologist consultant), one resident from the day surgery department, one resident from the dialysis unit, three nurses from the day surgery department, one nurse from the outpatient department, five nurses from the dialysis room, one echocardiography consultant, one consultant radiologist, and an anesthesia team composed of one consultant, two specialists and four operating room technicians. The collaboration was based on the adequate coordination and preparation of patients with ESRD in need of VA, by our team, for regular visits to the vascular surgery team at our referral kidney center. Initially, the visits were bimonthly, and from December 2011, the visits became on a monthly basis. The program was shifted from admission to day surgery from January 2011. The team used to stay for 1 to 2 days per visit to manage incident (n = 62) and prevalent (n = 195) patients with ESRD in need of HD. All procedures were in accordance with the ethical standards of the committee on human experimentation of our institution. A written informed consent was obtained from each subject. Different measures were taken in our department to improve the predialysis VA placement. This includes the establishment of a “low-clearance” clinic, where patients with stage 4 to 5 chronic renal failure are seen by a renal team (including a nephrologist, dialysis nurse, social worker, and dietician), who introduces the different modalities of renal replacement therapy, including the types of access required (peritoneal catheter or AVF). Furthermore, collaborations have been established with primary health care physicians for the education and early referral of such patients. These efforts have resulted, so far, in creating AVF in 62 incident patients over the course of this study. Our team prepared all patients in need of new VAs and previous complicated VAs before the arrival of the vascular surgery team. All our patients had their echocardiogram done by an echocardiologist consultant at our kidney center. Some patients went through Doppler ultrasound of the upper limbs and neck vessels. Other patients required computed tomography angiogram of neck vessels and superior vena cava. Clinical evaluation, laboratory investigations and HD sessions for all patients were performed one day prior to surgery. Patients who required general anesthesia had undergone full evaluation by our anesthesia team. Patients with ESRD from regional dialysis centers and/or satellite dialysis units were received by our team one day before operation. Clinical evaluation, revision of all investigations and consultations, if required, and
518
HD sessions were performed at our center one day before surgery. Vascular surgery operations were conducted simultaneously in two adjacent operating rooms. On surgery day, patients were received in the reception area of the day surgery unit. Clinical assessment and review of the investigations were rechecked by our staff. Intravenous access and other preoperative preparations were done by the nursing staff, and the patient was sent to the operating room once called. Postoperative patient was received back in the reception area and managed there by our staff. Within a period of 3 to 4 h, patients were ready to be discharged after appropriate evaluation and assessment. Reevaluation and assessment of the AVF was performed 4 to 6 weeks after surgical procedure. All usual nursing care measures were taken post-AVF creation until full maturation took place. Only in minority of the patients, who were either planning for kidney transplantation or where AVF or AVG creation was impossible, as well as those who refused the AVF creation, a permanent catheter was inserted by the vascular surgery team. In other patients, where AVF creation was impossible, AVG creation was done by the same vascular surgery team. On subsequent visits, the team managed to perform other minor procedures such as AVG embolectomy, AVG removal, AVG lymphocele excision, AVF ligation, and AVF aneurysmectomy. The visiting vascular surgery team managed 358 patients (306 patients from our kidney center and 52 patients from other satellite dialysis units), who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation (SD) age of patients was 52 ± 15 years with 62% male patients, including 84 (32.7%) who were diabetic. Over a period of 2 years, there were 15 visits of the vascular surgery team to our kidney center, where 408 procedures were performed with an average of 26 procedures completed per visit (Figure 1). The performed procedures include 293 AVFs, 56 AVGs, 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele and ligation of 1 AVF. There were 66 redos, which accounts for 25.7%. The sites of created AVF were brachiocephalic in 158 patients (56%), brachiobasilic in 26 patients (9%), radiocephalic in 21 patients (7%), and basilic transposition in 24 patients (9%). Based on adequate and maintained blood flow rate and luminal diameter of more than 0.4 cm assessed by ultrasound, the achieved AVF success rate exceeded 90%. The primary failure rate was 7% (18/257) and the late failure rate (after 2 years) was 8% (19/239). The waiting time
Hemodialysis International 2014; 18:516–521
Improving AVF rate
Table 1 Comparison between a group of our patients who previously dialyzed with catheters and patients who enrolled in this study with established and functioning AVF
Infection rate Clotting Blood flow rate Kt/V Hb Serum albumin Hospitalization
Catheter
AVF
P value
(n = 157) 6.1% 5.1% 214 + 32 0.88 + 0.19 9.2 + 1.2 3.2 + 0.5 6.1%
(n = 176) 0.6% 1% 298 + 37 1.28 + 0.2 10.9 + 0.9 3.7 + 0.4 3.8%
