Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres.

OBJECTIVE: It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed. METHODS: All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined - the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05. RESULTS: There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity. CONCLUSIONS: In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.

Renal replacement therapy for stage 5 chronic kidney disease in the Cayman Islands.

There has been no documentation on the epidemiology of end stage renal disease (ESRD) in the Cayman Islands. We retrospectively surveyed all facilities providing renal replacement therapy in the Cayman Islands in order to define the epidemiology of kidney failure in this setting. The prevalence of ESRD in this population was 0.975 persons per 1,000 population. There were 48 patients with kidney failure who received replacement therapy either by chronic hemodialysis (36) or kidney transplants (12). The method of access for maintenance hemodialysis was tunneled internal jugular catheter access (3), native arteriovenous fistulae (13) and prosthetic arteriovenous grafts (20). Currently, there is a low prevalence of maintenance hemodialysis by native fistulae (36.1%). A directed effort to increase the use of native fistulae is now necessary to meet the goals set by the National Kidney Foundation and Center for Medicaid Services. Otherwise, renal replacement therapy for patients with ESRD in the Cayman Islands exceeds the standards recommended by the National Kidney Foundation. In order to ensure continued delivery of modern quality care, further audits of the local practice will be required at regular intervals.

Access surgery for hemodialysis in the Cayman Islands: Preliminary results of a vascular access service.

OBJECTIVE: In the Cayman Islands, a vascular access service was created in 2005 to facilitate the creation of vascular access for hemodialysis by local surgeons. The present retrospective audit aims to establish the outcomes of this practice in the Cayman Islands. METHODS: Data from the operative log of the Cayman Islands Hospital was collected over a period of 36 months. The data were analyzed using SPSS version 12.0 (SPSS Inc, USA). Statistical analyses were performed using Student's t tests and Fisher's exact tests. RESULTS: A total of 19 operative procedures were performed to create vascular accesses in 12 men and seven women. Thirteen procedures (68%) created autogenous arteriovenous fistulas (AVFs) and six (32%) involved the insertion of a prosthetic arteriovenous graft (AVG). There were six incident dialysis patients, all of whom had an AVF created. The remaining 13 prevalent dialysis patients had new accesses in the form of AVFs (n=7) or AVGs (n=6). The statistical analyses were limited by sample size, but with AVFs, there were trends toward reduced incidence of secondary failure (four of 13 versus four of six), thrombosis (four of 13 versus two of six), infectious morbidity (zero versus two of six) and less demand for interventions to maintain patency (one of 13 versus two of six) with AVFs. There were also trends toward superior primary (461 days versus 227 days) and secondary (803 days versus 205 days) patency rates for AVFs. CONCLUSIONS: In this setting, the rate of AVF creation exceeds the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. To ensure continued delivery of modern quality care, further audits of the local practice will be required at regular intervals.

A sonographic study of kidney dimensions in a sample of healthy Jamaicans

A sonographic study of 49 randomly selected healthy Jamaicans was conducted to establish a guide for renal dimensions in the population. The mean length of the right kidney was 9.7 ñ 0.7 cm and the left 10 ñ 0.7 cm. The left kidney was longer than the right in the overall group and in males. There was no difference in width between right or left kidneys in the groups as a whole or within either gender. There was a significant association between the weight of males and the width of their kidneys; however, this association was not seen in females. The lone association between weight of the participants and renal length occurred in females and only with respect to the left kidney. Lengths and widths of kidneys were not associated with height in either gender. Renal surface area (RSA) was similar between the genders and also between right and left kidneys. Similarly, there was no significant association between renal length and body surface area (BSA) overall or within the genders. Renal index (RI) which is more reliable at assessing renal parenchymal mass than renal length alone was 20.92 and 22.86 for the right and left kidneys, respectively in males. Similarly, RI for the right and left kidneys in females was 23.76 and 25.54, respectively.