Current state of vascular access in Singapore.

This article described the current state of vascular access management for patients with end-stage renal disease in Singapore. Over the past 10 years, there has been a change in the demographics of end-stage renal disease patients. Aging population and the increase in prevalence of diabetes mellitus has led to the acceleration of chronic kidney disease and increase in incidence and prevalence of end-stage renal disease. Vascular access care has, therefore, been more complicated, with the physical, psychological, and social challenges that occur with increased frequency in elderly patients and patients with multiple co-morbidities. Arteriovenous fistula and arteriovenous graft are created by vascular surgeons, while maintenance of patency of vascular access through endovascular intervention has been a shared responsibility between surgeons, interventional radiologists, and interventional nephrologists. Pre-emptive access creation among end-stage renal disease patients has been low, with up to 80% of new end-stage renal disease patients being commenced on hemodialysis via a dialysis catheter. Access creation is exclusively performed by a dedicated vascular surgeon with arteriovenous fistula success rate up to 78%. The primary and cumulative patency rates of arteriovenous fistula and arteriovenous graft were consistent with the results from many international centers. Vascular access surveillance is not universally practiced in all dialysis centers due to its controversies, in addition to the cost and the limited availability of equipment for surveillance. Timely permanent access placement, with reduced dependence on dialysis catheters, and improved vascular access surveillance are the main areas for potential intervention to improve vascular access management.

Arteriovenous access practices in Australian and New Zealand dialysis units.

BACKGROUND: The creation and maintenance of dialysis vascular access is associated with significant morbidity. Structured management pathways can reduce this morbidity, yet practice patterns in Australia and New Zealand are not known. We aimed to describe the arteriovenous access practices in dialysis units in Australia and New Zealand. METHODS: An online survey comprising 51 questions was completed by representatives from dialysis units from both countries. In addition to descriptive analysis, responses were compared between units inside and outside of major cities. RESULTS: Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 38% of dialysis units in Australia and New Zealand. While 94% of units provided pre-dialysis education, only 60% reported a structured pre-dialysis pathway and 69% had a dedicated vascular access nurse. Most units routinely monitored fistula/graft function using flow rate measurement (73%) or recirculation studies (63%). A minority used routine ultrasound (35%). Thrombectomy, fistuloplasty and peritoneal dialysis catheter insertion were rarely performed by nephrologists (4%, 4% and 17% of units, respectively). Units outside of a major city were less likely to have access to a local vascular access surgeon (6/13 (46%) vs 35/35 (100%), P < 0.001). There were no other significant differences between units on the basis of location. CONCLUSION: Much variation exists in unit management of arteriovenous access. Structured pre-dialysis pathways and dedicated vascular access nurses may be underutilised in Australia and New Zealand. The use of regular access blood flow measurement and ultrasound is common in both countries despite a lack of data supporting its effectiveness. There is room for both practice improvement and a need for further evidence to ensure optimal arteriovenous access care.

Transcatheter Dialysis Conduit Procedures: Changing National and State-Level Medicare Use Patterns over 15 Years.

PURPOSE: To evaluate the changing use of transcatheter hemodialysis conduit procedures. METHODS: Multiple Centers for Medicare & Medicaid Services datasets were used to assess hemodialysis conduit angiography. Use was normalized per 100,000 beneficiaries and stratified by specialty and site of service. RESULTS: From 2001 to 2015, hemodialysis angiography use increased from 385 to 1,045 per 100,000 beneficiaries (compound annual growth rate [CAGR], +7.4%)]. Thrombectomy use increased from 114 to 168 (CAGR, +2.8%). Angiography and thrombectomy changed, by specialty, +1.5% and -1.3% for radiologists, +18.4% and +14.4% for surgeons, and +24.0% and +17.7% for nephrologists, respectively. By site, angiography and thrombectomy changed +29.1% and +20.7% for office settings and +0.8% and -2.4% for hospital settings, respectively. Radiologists' angiography and thrombectomy market shares decreased from 81.5% to 37.0% and from 84.2% to 47.3%, respectively. Angiography use showed the greatest growth for nephrologists in the office (from 5 to 265) and the greatest decline for radiologists in the hospital (299 to 205). Across states in 2015, there was marked variation in the use of angiography (0 [Wyoming] to 1173 [Georgia]) and thrombectomy (0 [6 states] to 275 [Rhode Island]). Radiologists' angiography and thrombectomy market shares decreased in 48 and 31 states, respectively, in some instances dramatically (eg, angiography in Nevada from 100.0% to 6.7%). CONCLUSIONS: Dialysis conduit angiography use has grown substantially, more so than thrombectomy. This growth has been accompanied by a drastic market shift from radiologists in hospitals to nephrologists and surgeons in offices. Despite wide geographic variability nationally, radiologist market share has declined in most states.

Dialysis therapy: Its past, present, and future? My personal recollection of dialysis therapy.

In Dr Ohira's era, hemodialysis was done using an external arteriovenous shunt. External arteriovenous shunts surely made repeated hemodialysis possible, but they also brought about serious complications which necessarily produced the arteriovenous fistula. Arteriovenous fistula is definitely the most important contribution to long-term survival of the hemodialysis patient. Hemodialysis therapy soon became very common, so that various kinds of patients appeared for it. Then came the era of arteriovenous grafts, because many patients lost good vessels in order to create the arteriovenous fistula. More grafts are now becoming available, which are made from different materials and in different forms, thus creating greater expectations for the future. Unfortunately, at this time, the revolutionary vascular access surpassing the arteriovenous fistula has yet to appear and we must continue to make proper application of the arteriovenous fistula. Vascular access is surely one of the important factors to assure a smooth dialysis life for patients. So, we must recognize that we play an important role in the dialysis patients' life. It is interesting to note that in every country, medical care exceeds physical care. This means that the mental factor somewhat compensates for the physical factor. Dr Ohira was a vascular surgeon, but he was also interested in the activities of daily living and quality of life, which must be one of the most delicate fields in medicine.

Practice patterns in arteriovenous fistula ligation among kidney transplant recipients in the United States Renal Data Systems.

BACKGROUND: Arteriovenous fistulas (AVF) and grafts (AVG) have been associated with significant cardiac morbidity that often improves after ligation. However, AV access ligation after kidney transplant (KT) is controversial due to concern for potential long-term allograft failure. We investigated US trends in AV access ligation after KT and the association between ligation and allograft failure. METHODS: All adult Medicare patients on pretransplant hemodialysis with a functioning AVF or AVG who underwent first-time KT were studied using the United States Renal Data Systems (January 2011 to December 2013). Post-transplant AV access ligation was determined using current procedural terminology codes. The incidence of post-transplant AV access ligation was described, and characteristics for patients undergoing ligation vs no ligation were compared. Kaplan-Meier curves and Cox proportional hazard models were then used to determine the association of AV access ligation with long-term allograft failure and all-cause mortality after accounting for patient characteristics, donor characteristics, and variation in transplant center practices. RESULTS: A total of 16,845 patients with functioning AVF/AVG received a KT during the study period. Of these, 779 (4.6%) underwent post-transplant AV access ligation. The proportion of patients who underwent ligation varied substantially between transplant centers, ranging from 0% (43.0% of centers) to >10% (11.0% of centers). Transplant recipients who underwent access ligation were more likely to be female (40.4% vs 36.6%), had lower median body mass index (27.6 vs 28.4 kg/m2), spent longer on dialysis pretransplant (4.2 vs 4.0 years), and were less likely to have renal failure secondary to diabetes compared with other etiologies (25.0% vs 34.9%) (all, P ≤ .03). Patients who underwent ligation were also more likely to have steal syndrome (77.2% vs 4.1%) and AV access infectious or aneurysmal complications (2.7% vs 0.7%) (both, P < .001). After adjusting for donor and recipient characteristics, increasing age (adjusted hazards ratio [aHR], 1.01; 95% confidence interval [CI], 1.00-1.01), increasing years on dialysis (aHR, 1.06; 95% CI, 1.00-1.13), zero human leukocyte antigen mismatch (aHR, 1.82; [95% CI, 1.09-3.05), and steal syndrome (aHR, 41.00; 95% CI, 34.56-48.64) were associated with post-transplant AV access ligation. Black race (aHR, 0.82; 95% CI, 0.69-0.98) and congestive heart failure (aHR, 0.66; 95% CI, 0.54-0.82) were negatively associated with ligation. Three-year allograft failure occurred in 4.9% ± 1.3% transplant recipients who underwent access ligation vs 9.5% ± 0.5% transplant recipients with functioning access (log-rank, P = .30), and was not significantly different between groups after risk adjustment (aHR, 0.81; 95% CI, 0.47-1.40). There was also no significant association between AV access and all-cause mortality after risk adjustment (aHR, 0.84; 95% CI, 0.46-1.54). CONCLUSIONS: Post-transplant AV access ligation is uncommon and generally reserved for patients with steal syndrome. Importantly, ligation is not associated with post-transplant allograft failure, which occurs in less than 10% of patients at 3 years. There also appears to be no reduction in all-cause mortality with AV access ligation. These data suggest that AV access ligation after KT can likely be reserved for access-related complications because the systemic benefits appear to be minimal.

Current status of dialysis and vascular access in Taiwan.

Due to the implementation of the National Health Insurance system in 1995, the number of patients receiving maintenance dialysis has increased rapidly. This contributed to Taiwan to be in an unfortunate position of possessing the highest prevalence of end-stage renal disease globally. Although the age-standardized incidence of end-stage renal disease gradually decreased to -1.1% in 2014, the huge economic burden that comes with dialysis is detrimental to the quality of dialysis treatment. To achieve a balance between economy and quality of care requires multidisciplinary cooperation. Through a variety of chronic kidney disease-related care projects, we have gradually reversed this situation and achieved good results. Further promotion of kidney transplantation and hospice care for terminal patients will improve the situation. With respect to vascular access, the "fistula first" policy is carried out and percutaneous transluminal angioplasty is the mainstay of treatment to resolve vascular access dysfunction. The medical expenses for dialysis and vascular access management are both fully paid for by the National Health Insurance, and patients do not have to worry about the medical expenses. However, the statistics and vascular access monitoring are relatively insufficient in the past. The comprehensive integration of vascular access management into public policy related to kidney disease will complete the missing piece of the puzzle of overall care.

Current treatment status and medical costs for hemodialysis vascular access based on analysis of the Korean Health Insurance Database.

BACKGROUND/AIMS: The Republic of Korea is a country where the hemodialysis population is growing rapidly. It is believed that the numbers of treatments related to vascular access-related complications are also increasing. This study investigated the current status of treatment and medical expenses for vascular access in Korean patients on hemodialysis. METHODS: This was a descriptive observational study. We inspected the insurance claims of patients with chronic kidney disease who underwent hemodialysis between January 2008 and December 2016. We calculated descriptive statistics of the frequencies and medical expenses of procedures for vascular access. RESULTS: The national medical expenses for access-related treatment were 7.12 billion KRW (equivalent to 6.36 million USD) in 2008, and these expenses increased to 42.12 billion KRW (equivalent to 37.67 million USD) in 2016. The population of hemodialysis patients, the annual frequency of access-related procedures, and the total medical cost for access-related procedures increased by 1.6-, 2.6-, and 5.9-fold, respectively, over the past 9 years. The frequency and costs of access care increased as the number of patients on hemodialysis increased. The increase in vascular access-related costs has largely been driven by increased numbers of percutaneous angioplasty. CONCLUSION: The increasing proportion of medical costs for percutaneous angioplasty represents a challenge in the management of end-stage renal disease in Korea. It is essential to identify the clinical and physiological aspects as well as anatomical abnormalities before planning angioplasty. A timely surgical correction could be a viable option to control the rapid growth of access-related medical expenses.

Utilization, patency, and complications associated with vascular access for hemodialysis in the United States.

BACKGROUND: This study examines the utilization and outcomes of vascular access for long-term hemodialysis in the United States and describes the impact of temporizing catheter use on outcomes. We aimed to evaluate the prevalence, patency, and associated patient survival for pre-emptively placed autogenous fistulas and prosthetic grafts; for autogenous fistulas and prosthetic grafts placed after a temporizing catheter; and for hemodialysis catheters that remained in use. METHODS: We performed a retrospective study of all patients who initiated hemodialysis in the United States during a 5-year period (2007-2011). The United States Renal Data System-Medicare matched national database was used to compare outcomes after pre-emptive autogenous fistulas, preemptive prosthetic grafts, autogenous fistula after temporizing catheter, prosthetic graft after temporizing catheter, and persistent catheter use. Outcomes were primary patency, primary assisted patency, secondary patency, maturation, catheter-free dialysis, severe access infection, and mortality. RESULTS: There were 73,884 (16%) patients who initiated hemodialysis with autogenous fistula, 16,533 (3%) who initiated hemodialysis with prosthetic grafts, 106,797 (22%) who temporized with hemodialysis catheter prior to autogenous fistula use, 32,890 (7%) who temporized with catheter prior to prosthetic graft use, and 246,822 (52%) patients who remained on the catheter. Maturation rate and median time to maturation were 79% vs 84% and 47 days vs 29 days for pre-emptively placed autogenous fistulas vs prosthetic grafts. Primary patency (adjusted hazard ratio [aHR], 1.26; 95% confidence interval [CI], 1.25-1.28; P < .001) and primary assisted patency (aHR, 1.36; 95% CI, 1.35-1.38; P < .001) were significantly higher for autogenous fistula compared with prosthetic grafts. Secondary patency was higher for autogenous fistulas beyond 2 months (aHR, 1.36; 95% CI, 1.32-1.40; P < .001). Severe infection (aHR, 9.6; 95% CI, 8.86-10.36; P < .001) and mortality (aHR, 1.29; 95% CI, 1.27-1.31; P < .001) were higher for prosthetic grafts compared with autogenous fistulas. Temporizing with a catheter was associated with a 51% increase in mortality (aHR, 1.51; 95% CI, 1.48-1.53; P < .001), 69% decrease in primary patency (aHR, 0.31; 95% CI, 0.31-0.32; P < .001), and 130% increase in severe infection (aHR, 2.3; 95% CI, 2.2-2.5; P < .001) compared to initiation with autogenous fistulas or prosthetic grafts. Mortality was 2.2 times higher for patients who remained on catheters compared to those who initiated hemodialysis with autogenous fistulas (aHR, 2.25; 95% CI, 2.21-2.28; P < .001). CONCLUSIONS: Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population.

Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients.

BACKGROUND: An arteriovenous fistula (AVF) is the recommended vascular access for hemodialysis (HD). Previous studies have not examined the resources and costs associated with creating and maintaining AVFs. STUDY DESIGN: Retrospective observational study. SETTING & PARTICIPANTS: Elderly US Medicare patients initiating hemodialysis therapy during 2010 to 2011. PREDICTOR: AVF primary and secondary patency and nonuse in the first year following AVF creation. OUTCOMES: Annualized vascular access costs per patient per year. RESULTS: Among patients with only a catheter at HD therapy initiation, only 54% of AVFs were successfully used for HD, 10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation. Mean vascular access costs per patient per year in the 2.5 years after AVF creation were $7,871 for AVFs that maintained primary patency in year 1, $13,282 for AVFs that experienced primary patency loss in year 1, $17,808 for AVFs that experienced secondary patency loss in year 1, and $31,630 for AVFs that were not used. Similar patterns were seen among patients with a mature AVF at HD therapy initiation and patients with a catheter and maturing AVF at HD therapy initiation. Overall, in 2013, fee-for-service Medicare paid $2.8 billion for dialysis vascular access-related services, ∼12% of all end-stage renal disease payments. LIMITATIONS: Lack of granularity with certain billing codes. CONCLUSIONS: AVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation.

Haemodialysis vascular access: current practices amongst Indian nephrologists.

INTRODUCTION: Despite the growing number of haemodialysis (HD) patients in India, little is known about vascular access practice. We investigated the use and cost of different vascular accesses by Indian nephrologists. METHODS: An online survey was emailed to 920 Indian nephrologists and 388 (42.1%) responded; 98.5% of whom were responsible for managing dialysis patients, 98% in hospitals. RESULTS: Sixty-four percent of patients initiated renal replacement therapy with HD, 7% with peritoneal dialysis, 10% kidney transplantation and 19% conservative care. Forty-eight percent of patients were self-paying, 26% had employee reimbursement and 23% had insurance. According to 59% of responders, more than three-quarters of patients started dialysis with uncuffed catheter, less than one-quarter started dialysis with fistula; and very few used grafts or tunnelled catheters. Among prevalent HD patients, over half were dialysing with fistula (79% nephrologists), rather than uncuffed catheters (15% nephrologists) or grafts (<1% nephrologists). Sixteen percent reported at least one catheter-related sepsis in more than half of patients. Placement of uncuffed catheters cost US$160 in 92% facilities, whereas tunnelled catheters cost US$320 in 46% of facilities. An arteriovenous fistula (AVF) could be created for US$160 in 40%, and US$320 in 90% of centres. Thirty-five percent of nephrologists reported that grafts were not placed at their institute and where they were available, the average cost was over US$480. Forty-six percent of nephrologists had access to pre-dialysis clinics, <30% to vascular access programmes, and <17% conducted regular vascular access audits. CONCLUSIONS: The survey provides a snapshot of the current status of vascular access care in HD patients and highlights need for pre-dialysis clinics, vascular access services and registry audits.

Impact of pay for performance on access at first dialysis in Queensland.

AIM: Commencement of haemodialysis with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is associated with improved survival compared with commencement with a central venous catheter. In 2011-2012, Queensland Health made incentive payments to renal units for early referred patients who commenced peritoneal dialysis (PD), or haemodialysis with an AVF/AVG. The aim of this study was to determine if pay for performance improved clinical care. METHODS: All patients who commenced dialysis in Australia between 2009 and 2014 and were registered with the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were included. A multivariable regression model was used to compare rates of commencing dialysis with a PD catheter or permanent AVF/AVG during the pay-for-performance period (2011-2012) with periods prior (2009-2010) and after (2013-2014). RESULTS: A total of 10 858 early referred patients commenced dialysis during the study period, including 2058 in Queensland. In Queensland, PD as first modality increased with time (P < 0.001) but there was no change in AVF/AVG rate at first haemodialysis (P = 0.5). In a multivariate model using the pay-for-performance period as reference, the odds ratio for commencement with PD or haemodialysis with an AVF/AVG in Queensland was 1.02 (95% CI 0.81-1.29) in 2009-2010 and 1.28 (95% CI 1.01-1.61) in 2013-2014. There was no change for the rest of Australia (0.97 95% CI 0.87-1.09 in 2009-2010 and 1.00 95% CI 0.90-1.11 in 2013-14). CONCLUSION: Pay for performance did not improve rates of commencement of dialysis with PD or an AVF/AVG during the payment period. A lag effect on clinical care may explain the improvement in later years.

A national appraisal of haemodialysis vascular access provision in Scotland.

PURPOSE: Published registry data demonstrate longstanding variation in the utilisation of different vascular access (VA) modalities between Scottish renal units; this may reflect different clinical processes between centres. A comprehensive appraisal was undertaken to understand the processes underpinning VA creation and maintenance across Scotland. METHODS: A mixed methods approach was utilised. Fifty-two semi-structured interviews were conducted with patients and clinicians in all ten, adult and paediatric, Scottish renal units. Interview transcripts were subjected to thematic analysis. Clinical activity data were prospectively collected for six weeks, and correlated with registry data. RESULTS: VA accounts for a large clinical workload. There was significant inter-centre variation in the utilisation of different VA modalities, and patients described frustrating, dissatisfying experiences. VA creation and maintenance pathways functioned best when nephrologists, surgeons and radiologists were co-located on the same campus with close multi-disciplinary working, protected clinical time, and proactive VA maintenance. No unit routinely measured or discussed procedure outcomes or strategic aspects of their service. CONCLUSIONS: Varied clinical outcomes reflected varied clinical processes. Optimised clinical pathways, staff education and measurement of clinical outcomes may improve VA service quality and facilitate safer, more effective, patient-centred care.

Variations in outcomes of hemodialysis vascular access by race/ethnicity in the elderly.

OBJECTIVE: Prevalence of end-stage renal disease, modality of treatment, and type of hemodialysis vascular access used varies widely by race/ethnicity in the United States, but outcomes of hemodialysis vascular access by race/ethnicity are poorly described. The objective of this study is to evaluate variations in outcomes of hemodialysis vascular access in the elderly by race/ethnicity. METHODS: Medicare outpatient, inpatient, and carrier files were queried from 2006 to 2011 for beneficiaries that were age ≥66 years and dialysis-dependent at time of index fistula/graft creation, qualified for Medicare by age only, and were continuously enrolled in Medicare 12 months before and after index fistula/graft creation. Primary outcome measures were early vascular access failure and 12-month failure-free survival, specifically, the variation in the difference between fistula and graft in non-White vs White race/ethnicity groups. RESULTS: Fistulas comprised a smaller proportion of index procedures performed in Blacks (65.9%; P < .001) and Asians (71.4%; P < .001), compared with Whites (78.0%) with no difference in Hispanics (78.7%; P = .59). Incidence of early failure after graft vs fistula was Whites, 34.9% vs 43.5% (P < .001), Blacks, 32.9% vs 49.1% (P < .001), Asians, 30.8% vs 40.5% (P = .014), and Hispanics 35.2% vs 43.2% (P = .005). The difference in early failure after fistula vs graft in Blacks was significantly larger than the difference in Whites (P < .001). The 12-month failure-free survival after index graft vs fistula was Whites 41.9% vs 38.9% (P = .008), Blacks 48.5% vs 37.3% (P < .001), Asians 51.6% vs 45.2% (P = .98), and Hispanics 51.9% vs 42.2% (P < .001). The difference in 12-month failure-free survival after graft vs fistula in Blacks and in Hispanics was larger than the difference in Whites (P < .001 and P = .02, respectively). CONCLUSIONS: Outcomes of fistulas vs grafts in the elderly vary significantly by race/ethnicity. The decreased risk of early failure after graft vs fistula creation is larger in Blacks compared with Whites. The higher failure-free survival at 12 months after graft vs fistula creation is larger in Blacks compared with Whites and trends toward being larger in Hispanics compared with Whites.

A cross-sectional study of dialysis practice-patterns in patients with chronic kidney disease on maintenance hemodialysis.

We studied the dialysis practice-patterns with regard to various aspects of chronic kidney disease (CKD) stage 5D, like anemia, mineral bone disease, vaccination, hospitalization, hypertension and cost of therapy. Four hundred and sixty-four adult hemodialysis (HD) patients from various dialysis centers of Mumbai were included in the study. The mean age of the study patients was 47.2 years. Temporary dialysis catheters were the most common initial vascular access. Thirteen percent of prevalent HD patients were on temporary catheters; 33% of patients had history of failure of arterio-venous fistula. The most common cause of failure was access thrombosis. About 75% of the patients had hemoglobin <11 g/dL and 35% had uncontrolled blood pressure. The prevalence of positive hepatitis B surface antigen and anti-hepatitis C virus antibody was 6% and 2%, respectively. The average cost of HD treatment was approximately 6100 Indian rupees (about US $100). HD is helpful in treating many of the clinical manifestations of CKD and postpones otherwise imminent death. However, dialysis treatment is no panacea to renal failure; HD patients have higher hospitalization rates and lower quality of life than the general population. The therapy itself brings with it a unique set of problems, such as vascular access-related complications, which cause significant mortality and morbidity. This study was a study of the current HD practices. The primary goal of this cross-sectional observational study is to understand dialysis practices and obtain data that can be used to improve care in the future.

The economic issue of vascular access within the Japanese medical reimbursement system.

We analyzed the current health economics of vascular access (VA) procedures in Japan. Results showed that the yearly VA-related medical expenses were as high as JPY20 billion and accounted for 1.4% of the total healthcare cost for chronic renal failure. The United States Renal Data System (USRDS) statistics showed that in the USA the yearly VA-related medical expenses accounted for 1.2% of the total medical cost for chronic renal failure, indicating that the costs did not differ much between the two countries. Moreover, percutaneous transluminal angioplasty (PTA) accounts for approximately 60% of VA procedures performed in Japan, and this ratio is increasing every year. Due to the aging of society and longer treatment periods, it is thought that PTA will become a significant procedure for the treatment of chronic renal failure in Japan.

UK organisation of access care.

National UK audits show that 73% of patients start renal replacement therapy (RRT) with haemodialysis (HD). However, 59% of those start HD on non-permanent access in the form of a tunnelled line (TL) or a non-tunnelled line (NTL), 40% on an arteriovenous fistula (AVF) and 1% on an arteriovenous graft (AVG). After 3 months, the number of patients dialysing on AVF was only 41%. Late referrals, within 90 days of starting dialysis to the renal service, occur in one-fifth of all incident HD patients. Referral to a surgeon was an important determinant of mode of access at first dialysis. However, referral to a surgeon occurred in 67% of patients who were known to the nephrologist for over a year and in 46% of patients who were known to nephrology less than a year but more than 90 days. Best practice tariffs of the National Health Service (NHS) payment by results program have set a target of 75% of prevalent HD occurring via an AVF or AVG in 2011/2012, rising to 85% in 2013/2014. We suggest that this target is best achieved by increasing timely referral to a surgeon for creation of access before HD is needed.

Variability in anesthetic considerations for arteriovenous fistula creation.

INTRODUCTION: Anesthetic options for arteriovenous fistula (AVF) creation include regional anesthesia (RA), general anesthesia (GA) and local anesthetic for select cases. In addition to the benefits of avoiding GA in high-risk patients, recent studies suggest that RA may increase perioperative venous dilation and improve maturation. Our objective was to assess perioperative outcomes of AVF creation with respect to anesthetic modality and identify patient-level factors associated with variation in contemporary anesthetic selection. METHODS: National Surgical Quality Improvement Project (NSQIP) data (2007-2010) were accessed to identify patients undergoing AVF creation. Univariate analysis and multivariate logistic regression were performed to assess the relationships among patient characteristics, anesthesia modality and outcome. RESULTS: Of 1,540 patients undergoing new upper extremity AVF creation, 52% were male and 81% were younger than 75 years. Anesthesia distribution was GA in 85.2%, local/monitored anesthetic care (MAC) in 2.9% and RA in 11.9% of cases. By multivariate analysis, independent predictors of RA were dyspnea at rest (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.1-4.9), age >75 (HR 1.6, 95% CI 1.1-2.3) and teaching hospital status as indicated by housestaff involvement (HR 3.7, 95% CI 2.5-5.5). RA was associated with higher total operative time, duration of anesthesia, length of time in operating room and duration of anesthesia start until surgery start (p<0.01). There were no differences between perioperative complications or mortality among anesthetic modalities, although all deaths occurred in the GA group. DISCUSSIONS: Despite recent reports highlighting potential benefits of RA for AVF creation, GA was surprisingly used in the vast majority of cases in the United States. The only comorbidities associated with preferential RA use were advanced age and dyspnea at rest. Practice environment may influence anesthetic selection for these cases, as a nonteaching environment was associated with GA use. The trend seen here toward higher mortality in GA and the potential perioperative benefits of RA for the access should encourage more widespread use of RA in practice for this high-risk patient population.

Vascular access morbidity and mortality: trends of the last decade.

During the past decade, clear trends in the types of incident and prevalent hemodialysis vascular access can be observed. There has been a steady increase and recent stabilizaton of patients initiating hemodialysis with a central venous catheter, representing approximately 80% of all incident accesses. There has also been a steady increase in prevalent fistula use, currently greater than 50% within 4 months of hemodialysis initiation. Patient and vascular access related morbidity and mortality are reflected in the type of vascular access used at initiation and for long-term maintenance dialysis. There is a three- to fourfold increase in risk of infectious complications in patients initiating dialysis with a catheter compared with either a fistula or graft and a sevenfold higher risk when the catheter is used as a prevalent access. Procedure rates have increased two- to threefold for all types of access. There is a significant increased risk of mortality associated with catheter use, especially within the first year of dialysis initiation.

Achieving the goal: results from the Fistula First Breakthrough Initiative.

PURPOSE OF REVIEW: This review summarizes the background and implementation of the Fistula First Breakthrough Initiative (FFBI), published information about changes in vascular access practice since its inception, and several issues raised by the program. RECENT FINDINGS: The FFBI is a surveillance system using the End-Stage Renal Disease (ESRD) Networks to spread improvement ideas. Concomitant with implementation of the program, prevalent arteriovenous fistula use has increased an average of 3.3% annually since 2003, an incremental improvement of 1.3% over the preexisting trend. At the same time, long-term central venous catheter (CVC) use declined among the prevalent population. Increasingly, individual facilities are achieving the FFBI goal of 66% prevalent arteriovenous fistula use; however, results vary across geographic regions and are not explained by patient demographic and clinical characteristics alone. SUMMARY: ESRD Network interventions as a function of the FFBI are associated with increasing arteriovenous fistula use and likely contributed to improvement, but improvement cannot be unequivocally attributed to the Networks due to lack of rigorous research design. Questions and opportunities remain. It is not yet clear how to identify patients who may not be appropriate candidates for an arteriovenous fistula. The ultimate impact of the FFBI on patient mortality is yet to be determined. The FFBI must continue to identify variations in use and the contributing causes, and implement strategies to address these causes if the FFBI goal is to be fully achieved.