Expert recommends patient-centered vascular access approach that considers race, sex, age
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Contending a Kidney Disease Outcomes Quality Initiative update acknowledges a lack of evidence on how to achieve optimal access for dialysis, a vascular surgeon recommended a more patient-centered approach accounting for race, sex and age.
“There are a few special populations with respect to vascular access decision-making that could be considered ‘low-hanging fruit’ when it comes to identifying factors we should think about during the decision-making process,” Karen Woo, MD, MS, an associate professor of surgery at the University of California, Los Angeles, said during her virtual presentation at ASN Kidney Week.
These special populations, according to Woo, are Black patients, women and older patients.
Woo cited data showing that, compared with white patients, Black patients are more likely to have a graft than fistula for access. In addition, Black patients appear to have a higher incidence of repeat vascular access creation and a shorter time to second vascular access.
Regarding patient sex, she said, “There have been many studies with conflicting results. Some studies have shown that female sex is associated with higher fistula non-maturation rates and decreased patency.”
Although this has been theorized to be related to women having a smaller vein diameter than men, Woo cited two studies: one which demonstrated no association between sex and cephalic vein diameter and one which concluded the lower maturation rate in women was not explained by vein diameter.
Addressing age, Woo argued that older age is associated with an increased risk of mortality and may be associated with worse vascular access outcomes.
“It remains challenging to set an age cutoff for what should be considered elderly,” she said.
“One factor that may help with this is frailty. Over one-third of hemodialysis patients meet the criteria for frailty, and frailty independently predicts mortality.”
Study results show patients in the highest quartile of frailty have an increased risk of primary fistula failure even when adjusting for age, according to Woo.
“As clinicians, the question is: What do we do with this data?” Woo asked. “How do we balance all of these factors to arrive at the optimal access for an individual patient?”
Based on a study in which patients reported their experience with vascular access, Woo recommended patient involvement be at the center of the decision-making process.
Key findings of the study included that many patients did not have a “centralized trustworthy resource” nor an adequate understanding of their options.
“Patients saw the choice to pursue dialysis as a choice between life and death,” Woo said. “And as such, [that was] not much of a choice. They saw their access as the lifeline to dialysis and a necessary tool in order to achieve dialysis, which was the priority.”
Further, she noted “study participants had firmly held beliefs regarding qualities that they felt reflected trustworthiness of the physician.”
Specifically, Woo said patients strongly valued physicians they perceived as being “generous with their time, who gave thorough explanations and who listened carefully.”
According to Woo, if patients felt a physician was impatient, they perceived it as arrogance and if they felt the staff was incompetent, patients were less likely to trust their physician.
“They were particularly alienated by physicians who did not follow up appropriately after significant events,” she added, stressing that patients placed great value on long-term relationships with their care providers.
“The most important thing we can do for our patients is to talk to them and listen to them and their family members,” Woo concluded. “We, as physicians, need to do what we can to engage the patients and their supportive others in the vascular access decision-making process and make every effort to inform them and empower them to make self-efficacious decisions.”
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Woo K. Vascular access in unique patient populations: Race, sex, and elderly age. Presented at: ASN Kidney Week. Oct. 22-25, 2020 (virtual meeting).
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