Cardiac implantable electronic device and vascular access: Strategies to overcome problems.

For arrhythmia treatment or sudden cardiac death prevention in hemodialysis patients, there is a frequent need for placement of a cardiac implantable electronic device (pacemaker, implantable cardioverter defibrillator, or cardiac resynchronization device). Leads from a cardiac implantable electronic device can cause central vein stenosis and carry the risk of tricuspid regurgitation or contribute to infective endocarditis. In patients with end-stage kidney disease requiring vascular access and cardiac implantable electronic device, the best strategy is to create an arteriovenous fistula on the contralateral upper limb for a cardiac implantable electronic device and avoidance of central vein catheter. Fortunately, cardiac electrotherapy is moving toward miniaturization and less transvenous wires. Whenever feasible, one should avoid transvenous leads and choose alternative options such as subcutaneous implantable cardioverter defibrillator, epicardial leads, and leadless pacemaker. Based on recent reports on the leadless pacemaker/implantable cardioverter defibrillator effectiveness, in patients with rapid progression of chronic kidney disease (high risk of renal failure) or glomerular filtration rate <20 mL/min/1.73 m2, this option should be considered by the implanting cardiologist for future access protection.

What is the best setting for receiving dialysis vascular access repair and maintenance services?

INTRODUCTION: Advances in dialysis vascular access (DVA) management have changed where beneficiaries receive this care. The effectiveness, safety, quality, and economy of different care settings have been questioned. This study compares patient outcomes of receiving DVA services in the freestanding office-based center (FOC) to those of the hospital outpatient department (HOPD). It also examines whether outcomes differ for a centrally managed system of FOCs (CMFOC) compared to all other FOCs (AOFOC). METHODS: Retrospective cohort study of clinically and demographically similar patients within Medicare claims available through United States Renal Data System (USRDS) (2010-2013) who received at least 80% of DVA services in an FOC (n = 80,831) or HOPD (n = 133,965). Separately, FOC population is divided into CMFOC (n = 20,802) and AOFOC (n = 80,267). Propensity matching was used to control for clinical, demographic, and functional characteristics across populations. RESULTS: FOC patients experienced significantly better outcomes, including lower annual mortality (14.6% vs. 17.2%, p<0.001) and DVA-related infections (0.16 vs. 0.20, p<0.001), fewer hospitalizations (1.65 vs. 1.91, p<0.001), and lower total per-member-per-month (PMPM) payments ($5042 vs. $5361, p<0.001) than HOPD patients. CMFOC patients had lower annual mortality (12.5% vs. 13.8%, p<0.001), PMPM payments (DVA services) ($1486 vs. $1533, p<0.001) and hospitalizations ($1752 vs. $1816, p<0.001) than AOFOC patients. CONCLUSIONS: Where nephrologists send patients for DVA services can impact patient clinical and economic outcomes. This research confirmed that patients who received DVA care in the FOC had better outcomes than those treated in the HOPD. The organizational culture and clinical oversight of the CMFOC may result in more favorable outcomes than receiving care in AOFOC.