Preventing Vascular Access Dysfunction: Which Policy to Follow

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Abstract

In the USA, three Clinical Performance Measures are currently in place: increasing the number of autologous arteriovenous fistulas (AVFs) among incident hemodialysis patients to 50% and to 40% in prevalent hemodialysis patients; to foster the surveillance of accesses with pre-emptive correction of problems before accesses thrombose or fail, and to reduce the use of catheters in prevalent patients to less than 10%. Reduction of catheters will automatically result from initiatives that increase the construction of AVFs and pre-emptive monitoring and surveillance of accesses for dysfunction. Therefore, policies that promote the latter two vascular access aspects are most important to develop and follow. Of these two, however, the most impact will be made by promoting a policy to increase AVF creation in the timeliest manner possible. Strategies and resources needed to achieve these policies are presented. The need for a team approach is emphasized.

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Most cited references 6

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Hemodialysis access failure: a call to action.

R Hakim, J Himmelfarb (1998)

Recent evidence suggests that the cost as well as the morbidity associated with the maintenance of hemodialysis access is increasing rapidly; currently, the cost exceeds 1 billion dollars and access related hospitalization accounts for 25% of all hospital admissions in the U.S.A. This increase in cost and morbidity has been associated with several epidemiological trends that may contribute to access failure. These include late patient referral to nephrologists and surgeons, late planning of vascular access as well as a shift from A-V fistulaes to PTFE grafts and temporary catheters, which have a higher failure rate. The reasons for this shift in the types of access is multifactorial and is not explained by changes in the co-morbidities of patients presenting to dialysis. Surgical preference and training also appear to play an important role in the large regional variation and patency rate of these PTFE grafts. We propose a program for early placement of A-V fistulae, a continuous quality improvement, multidisciplinary program to monitor access outcome, the development of new biomaterials, and a research plan to investigate pharmacological intervention to reduce development of stenosis and clinical interventions to treat those that do develop, prior to thrombosis.

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Change in access blood flow over time predicts vascular access thrombosis.

Y Shyr, Ira Schulman, J Himmelfarb … (1998)

Vascular access thrombosis accounts for at least $1 billion dollars in annual expenses and 25% of hospitalizations for chronic hemodialysis patients. Low vascular access blood flow (less than 800 ml/min) has been shown to modestly increase the relative risk for thrombosis in the subsequent three months. In this study, it is hypothesized that a time-dependent decrease in vascular access blood flow may be more predictive of subsequent thrombosis especially in vascular accesses with flows more than 800 ml/min, since it would indicate the development of a critical outlet stenosis in the graft. Ninety-five accesses in 91 CHD patients were prospectively followed over 18 months. Vascular access blood flow was measured every six months by the ultrasound dilution technique. Thrombotic events were recorded during the three study periods. A total of 34 thrombotic events in 95 accesses were documented through the total study duration. Accesses that thrombosed had a 22% decrease in vascular access blood flow during the first observation period and a further 41% decrease during the second observation period as compared to 4% drop and 15% increase during the first and second observation periods, respectively, for accesses that did not thrombose. There was an estimated 13.6-fold (95%, confidence interval 2.68 to 69.16) increase in the relative risk of thrombosis for accesses with more than 35% decrease in vascular access blood flow compared to those accesses with no change in blood flow. There was no statistical difference in the average vascular access blood flow of all patients over the study period. Accesses that show a large (>15%) decrement in vascular access blood flow are associated with a high risk of thrombosis. Serial measurements of vascular access blood flow predict access thrombosis.

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Graft flow as a predictor of thrombosis in hemodialysis grafts.

Peter J. Blankestijn, Willem-Maarten P F Bosman, F Boereboom … (1998)

The effort to reduce the incidence of graft thrombosis is mainly based on predicting venous stenosis by measuring venous drip chamber pressures. In this study we evaluated whether graft flow measurements, using an ultrasound dilution technique, would be of additional value to identify patients at risk for thrombosis. In fifty consecutive patients with a bridge graft we measured graft flow and venous drip chamber pressure at a dialyzer blood flow of 200 ml/min. The results of these flow measurements were not used for selection of patients, nor for a diagnostic or therapeutic procedure. All thrombotic events and (radiological or surgical) interventions were registered. A total of 17 patient-years were analyzed. In 17 patients an intervention was done, and in 18 patients thrombosis occurred. The incidence rate of thrombosis was higher in patients with a flow 600 ml/min (N = 37; rate ratio 7. 2; 95% CI, range 2.84 to 18.24, P 600 ml/min. In the remaining 32 patients only two developed spontaneous thrombosis. Remarkably, venous drip chamber pressure measurements did not discriminate between patients with graft flow > or < 600 ml/min, and showed a wide range in patients who developed spontaneous thrombosis within two months. We suggest that graft flow measurements are helpful in selecting patients at risk for graft thrombosis.

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Author and article information

Journal

Journal ID (publisher-id): BPU

Journal ID (nlm-ta): Blood Purif

Journal ID (doi): 10.1159/issn.0253-5068

Title: Blood Purification

Publisher: S. Karger AG

ISBN: 978-3-8055-7372-6

ISBN: 978-3-318-00813-5

ISSN (Print): 0253-5068

ISSN (Electronic): 1421-9735

Publication date Subscription-year: 2002

Publication date (Print): 2002

Publication date (Electronic): 17 January 2002

Volume: 20

Issue: 1

Pages: 26-35

Affiliations

Division of Nephrology, Department of Medicine, University of West Virginia School of Medicine, Morgantown, W.Va., USA

Article

Publisher ID: 46982 Other ID: Blood Purif 2002;20:26–35

DOI: 10.1159/000046982

PubMed ID: 11803156

SO-VID: b92eed4e-6cd5-4f19-85e4-fc3a27d33760

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Preventing Vascular Access Dysfunction: Which Policy to Follow

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Abstract

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Karger: Nephrology

Most cited references 6

Hemodialysis access failure: a call to action.

Change in access blood flow over time predicts vascular access thrombosis.

Graft flow as a predictor of thrombosis in hemodialysis grafts.

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