‘Glaring hole’ exists in the understanding of successful dialysis access creation
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According to a speaker at ASN Kidney Week, there is a “glaring hole” in data related to successful dialysis access creation, presenting challenges to nephrologists as they attempt to improve care and increase patient satisfaction.
“A patient that undergoes dialysis vascular access surgery is not like a patient who undergoes other surgeries,” Dirk M. Hentschel, MD, FASN, of Brigham and Women’s Hospital, said in his virtual presentation. “If you undergo cholecystectomy, then there is a binary outcome, in which the gall bladder is either in place or not. If you have a fistula created, there is a 50/50 chance that the fistula will not mature and even if it matures physiologically, it may not be usable in the dialysis unit.”
Adding that grafts are associated with a high frequency of thrombosis, while tunneled catheters create can suppress nutritional status and cause other complications (including central vein stenoses, occlusions and infections), Hentschel posed the question: “How, as nephrologists, do we ask our patients to undergo dialysis access creation, ideally before they reach end-stage renal disease and often at a time when there’s little clarity whether renal replacement therapy will be needed?”
Hentschel contended evidence suggests many factors determine if vascular access creation surgery will be successful. One of these factors is the number of fistulas a surgeon creates annually, with data showing surgeons who perform more of these surgeries appear to have better success rates. He cited a 2019 study from the American Journal of Kidney Diseases that indicated surgeons in the top category of annual creations have an 80% success rate compared with 40% for those in the bottom category.
According to Hentschel, there is uncertainty regarding what surgeons who have high success rates do differently. Therefore, he suggested, it may be useful to also consider processes of care, noting that “intense” care patterns (including venograms, follow up, imaging and continuous monitoring) are associated with patency rates in the 85% range. “Even in the more difficult to create forearm fistulas, the rates are still in the 70% to 90% range,” he added.
Still, he argued it is unknown what specific elements in process of care make a difference.
“This leads us to this conclusion,” Hentschel said. “Solving the questions in dialysis access care requires understanding all the contributing factors: not only the patient and his or her biological contributors, but also the surgeons and interventionalists who are involved, as well as the dialysis staff and the processes of care in the place where the patient has accesses created. Only based on this understanding can we then create ‘the right access for the right patient at the right time.’”
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Hentschel DM. Introduction to personalizing care in dialysis vascular access: Putting the patient first. Presented at: ASN Kidney Week. Oct. 22-25, 2020 (virtual meeting).
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