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The multidisciplinary approach to hemodialysis vascular access at the Mount Sinai Hospital
Joseph A Vassalotti1, Abigail Falk, Victoria Teodorescu
1Nephrology Division, Box 1243, Mount Sinai School of Medicine, One East 100th Street, New York, NY 10029-6574, USA. Joseph.Vassalotti@mssm.edu
Insights
Implementing a multidisciplinary approach significantly increases arteriovenous fistula use for hemodialysis patients, reducing reliance on catheters and improving outcomes. This strategy enhances vascular access for end-stage renal disease treatment.
Area of Science:
- Nephrology
- Vascular Surgery
- Interventional Radiology
Background:
- End-stage renal disease patients often require hemodialysis, with vascular access complications being major causes of morbidity and mortality.
- Catheters and grafts present higher risks of infection and thrombosis compared to arteriovenous fistulas.
- Arteriovenous fistulas are the preferred vascular access for hemodialysis due to lower complication rates.
Purpose of the Study:
- To evaluate the impact of a multidisciplinary team approach on increasing arteriovenous fistula utilization in hemodialysis.
- To review the roles of various specialists in a multidisciplinary program for optimizing hemodialysis access.
- To highlight the importance of preoperative vein mapping and stenosis screening.
Main Methods:
- A weekly multidisciplinary team meeting involving nephrologists, vascular surgeons, interventional radiologists, nurses, and fellows.
- Preoperative hemodialysis access vein mapping using Doppler ultrasound.
- Screening techniques for early detection of arteriovenous graft stenosis.
Main Results:
- The utilization of arteriovenous fistulas in the Mount Sinai outpatient hemodialysis program increased from 15% to 43% (p<0.001) since the program's inception in 1998.
- The multidisciplinary program substantially limited the use of catheters for hemodialysis access.
- Improved outcomes in hemodialysis patients are associated with increased AV fistula use.
Conclusions:
- A collaborative, multidisciplinary approach is effective in promoting the use of arteriovenous fistulas for hemodialysis.
- This strategy leads to a significant reduction in catheter-dependent hemodialysis and associated complications.
- Optimizing vascular access through teamwork and advanced imaging improves patient care in end-stage renal disease.
Abstract:
A majority of the quarter of a million end-stage renal disease patients nationwide are treated with hemodialysis. Important and frequent causes of morbidity and mortality, when they undergo this procedure, include vascular access infection and thrombosis associated with the use of catheters and, to a lesser extent, grafts. Therefore, an arteriovenous (AV) fistula is the preferred hemodialysis access. A multidisciplinary approach, including nephrologists, vascular surgeons, interventional radiologists, nurses, nephrology fellows, and nephrology physician assistants, meeting together weekly, should improve hemodialysis outcomes by promoting the use of AV fistulas. The specific roles of the interventional radiologist, vascular surgeon, nephrologist and other members of the multidisciplinary team are reviewed. Important additional components of this program are Doppler ultrasound for preoperative hemodialysis access vein mapping and screening techniques for early detection of arteriovenous graft stenosis. The use of arteriovenous fistulas in the Mount Sinai outpatient hemodialysis program has increased from 15% to 43% (p<0.001) and substantially limited catheter use since 1998, when the multidisciplinary program began.
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