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First hemodialysis access selection varies with patient acuity.

A L Friedman1, C Walworth, C Meehan

  • 1Yale University School of Medicine, New Haven, CT, USA.

Advances in Renal Replacement Therapy
|October 29, 2000
PubMed
Summary

Patients with unpredicted end-stage renal disease (ESRD) are common and less likely to receive a native arteriovenous (AV) fistula for hemodialysis. This impacts the quality of vascular access for emergent dialysis needs.

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Area of Science:

  • Nephrology
  • Vascular Surgery
  • Public Health

Background:

  • National Kidney Foundation Dialysis Outcomes Quality Improvement (NKF-DOQI) guidelines recommend native arteriovenous (AV) fistulae as the preferred vascular access for hemodialysis patients.
  • The course of progression to end-stage renal disease (ESRD) may influence the selection of initial vascular access.

Purpose of the Study:

  • To investigate if patients' clinical course to ESRD affected the selection of initial hemodialysis vascular access.
  • To assess the adequacy of initial vascular access in different patient groups.

Main Methods:

  • A retrospective study of 240 incident hemodialysis patients from 6 centers in Network One's Vascular Access Quality Improvement Project (QIP).
  • Patients were categorized into three groups: KNOWN (predictable progression), CRISIS (unanticipated medical crisis), and UNKNOWN (undiagnosed chronic renal insufficiency).

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  • Initial vascular access types (fistula, graft, catheter) and their functionality at 2 months were analyzed.

    • Main Results:

    • Only 43% of patients had a predictable progression to ESRD.
    • The most frequent initial access was a catheter (54%), followed by fistula (29%) and graft (16%).
    • KNOWN patients were significantly more likely to receive a fistula (46%) compared to CRISIS or UNKNOWN patients (P <.001). Initial access supported dialysis in 53.7% of KNOWN, 59.4% of CRISIS, and 45.7% of UNKNOWN patients after 2 months.

    Conclusions:

    • Unpredicted onset of ESRD is common, with these patients less likely to receive a preferred AV fistula.
    • Current vascular access selection practices may not adequately address the needs of patients with unforeseen dialysis requirements.
    • Further research is needed to define optimal vascular access management strategies for patients with emergent dialysis needs.