Effect of first cannulation time and dialysis machine blood flows on survival of arteriovenous fistulas.

Background: To study the effect of cannulation time on arteriovenous fistula (AVF) survival. Methods. Analysis of two prospective databases of access operations and dialysis sessions from 12 January 2002 through 4 January 2015 with follow-up until 4 January 2016. First cannulation time (FCT), defined from operation to first cannulation, was categorized as <2 weeks, 2-4 weeks, 4-8 weeks, 8-16 weeks and ≥16 weeks. Early cannulation was defined as FCT within 4 weeks. AVF survival was defined as the date until the AVF was abandoned. Maximum machine blood flow rate (BFR) for the first 29 dialysis sessions on AVF was analysed. Results: Altogether, 1167 AVF with functional dialysis use were analysed: 667 (57%) radial cephalic AVF, 383 (33%) brachiocephalic AVF and 117 (10%) brachiobasilic AVF. The 631 (54%) AVF created in on-dialysis patients were analysed separately from 536 (46%) AVF created in pre-dialysis patients. AVF survival was similar between cannulation categories for both pre-dialysis patients (P = 0.19) and on-dialysis patients (P = 0.83). Early cannulation was associated with similar AVF survival in both pre-dialysis patients (P = 0.82) and on-dialysis patients (P = 0.17). Six consecutive successful cannulations from the start were associated with improved AVF survival (P = 0.0002). A below-median BFR at the start of dialysis was associated with better AVF survival (P < 0.0001). A below-median increase in BFR in the first 2 months was associated with worse AVF survival (P = 0.007). The type of AVF, diabetes, pre-dialysis state at operation and six successful cannulations from the start were independent predictors for AVF survival. Conclusions: FCT is not associated with AVF survival. Failures to achieve six successful cannulations from the start of dialysis and higher machine BFR in the first week of dialysis are associated with decreased AVF survival.

Effect of ethnicity and socioeconomic status on vascular access provision and performance in an urban NHS hospital.

BACKGROUND: The aim of this study was to examine the effect of ethnicity, socioeconomic group (SEG) and comorbidities on provision of vascular access for haemodialysis (HD). METHODS: This was a retrospective review of two databases of HD sessions and access operations from 2003-11. Access modality of first HD session and details of transplanted patients were derived from the renal database. Follow-up was until 1 January 2015. Primary failure (PF) was defined as an arteriovenous fistula (AVF) used for fewer than six consecutive dialysis sessions. AVF survival was defined as being until the date the AVF was abandoned. Ethnicity was coded from hospital records. SEG was calculated from postcodes and 2011 census data from the Office of National Statistics. Comorbidities were calculated with the Charlson Comorbidity Index. RESULTS: Five hundred incident patients started chronic HD in the study period. Mode of starting HD was not associated with ethnicity (P = 0.27) or SEG (P = 0.45). Patients from ethnic minorities were younger when starting dialysis (P < 0.0001). Some 928 AVF patients' first AVF operations were analysed: 68% Caucasian, 26% Asian and 6% Afro-Caribbean. Half were in the most deprived SEG and 11% in the least deprived SEG. PF did not differ by ethnicity (P = 0.29), SEG (P = 0.75) or comorbidities (P = 0.54). AVF survival was not different according to ethnicity (P = 0.13) or SEG (P = 0.87). AVF survival was better for patients with a low comorbidity score (P = 0.04). The distribution of transplant recipients by ethnic group and SEG was similar to the distributions of all HD starters. CONCLUSION: Ethnicity and socioeconomic group had no effect on mode of starting HD, primary AVF failure rate or AVF survival. Ethnic minorities were younger at start of dialysis and at their first AVF operation.

Is early cannulation of an arteriovenous fistula associated with early failure of the fistula?

OBJECTIVE: To study the effect of early cannulation of arteriovenous fistulas (AVF) on early AVF failure. METHODS: Analysis of two databases of access operations and dialysis sessions from 1/12/2002 till 1/4/2015. Follow-up until 1/4/2016. Functional dialysis use defined as six consecutive cannulations of the AVF with two needles. Early cannulation defined as needling of the AVF within 30 days of creation. Early failure was defined as abandonment for new form of access within 90 days of first cannulation. Machine blood-flow rates (BFR) of each dialysis session for the first 2 months collected from the dialysis database. RESULTS: We analysed 1167 AVFs with functional dialysis use. Some 148 AVFs (11%) were needled within 30 days. Early needling was not associated with increased early failure rates (p = 0.43). Early failure rates were lower in AVFs with six consecutive successful cannulations from the start (p = 0.002). There was a trend of reduced early failure rates (test for trend: p = 0.018) in the latter years of the study period, but no trend in early cannulation rates (p = 0.19). Failure to achieve six successful cannulations from the start was an independent predictor of early AVF failure but early needling was not an independent predictor in multivariate analysis. Average starting BFRs were higher in AVF that were needled early. CONCLUSIONS: Early cannulation was not associated with early failure. Failure to achieve six successful cannulations from the start was an independent predictor of early failure. The trend in yearly variation of early failure rates suggests that evolving practices influenced early failure rates.

Access ligation in transplant patients.

Access surgeons will encounter patients with functioning transplants who want to lose their fistula, and every dialysis unit sees patients returning after a failed kidney transplant for whom an old fistula is a readily available lifeline. The decision is straightforward in patients with perfectly functioning transplants and disabling complications of their fistula, or in patients with failing transplants and a good fistula. The challenge is to make this decision in patients with good transplant function and an asymptomatic fistula. Despite improvements in one-year survival of renal grafts, the long-term graft survival has improved modestly. This means about half of the patients with a successful kidney transplant will return to dialysis within 10 years. Use of recently developed risk calculators, based on clinical parameters, may help in the decision process. A high flow fistula can lead to heart failure but most fistulae are well tolerated in asymptomatic patients and the effects of closure of the AVF on the heart are modest. Recent evidence suggests that there may be benefits of a functioning AVF that may need to be considered in this decision process. This article reviews the literature and comes to pragmatic recommendations of what to do with this conundrum.

Systematic kidney disease management in a population with diabetes mellitus: turning the tide of kidney failure.

PROBLEM: A significant proportion of patients with diabetes mellitus do not get the benefit of treatment that would reduce their risk of progressive kidney disease and reach a nephrologist once significant loss of kidney function has already occurred. DESIGN: Systematic disease management of patients with diabetes and kidney disease. SETTING: Diverse population (approximately 800,000) in and around Birmingham, West Midlands, UK. KEY MEASURES FOR IMPROVEMENT: Number of outpatient appointments, estimated glomerular filtration rate (eGFR) at first contact with nephrologist, number of patients starting kidney replacement therapy (KRT) and mode of KRT at start. STRATEGY FOR CHANGE: Identification of patients with low or deteriorating trend in eGFR from weekly database review, specialist diabetes-kidney clinic, self-management of blood pressure and transfer to multidisciplinary clinic >12 months before end-stage kidney disease. EFFECTS OF CHANGE: New patients increased from 62 in 2003 to 132 in 2010; follow-ups fell from 251 to 174. Median eGFR at first clinic visit increased from 28.8 ml/min/1.73 m(2) (range 6.1-67.0) in 2000/2001 to 35.0 (11.1-147.5) in 2010 (p<0.006). In 2010, the number of patients starting KRT fell 30% below the projected activity using 1993-2003 data as baseline (p<0.003). The proportion starting KRT with either a kidney transplant, peritoneal dialysis or haemodialysis via an arteriovenous fistula increased from 26% in 2000 to 55% in 2010. LESSONS LEARNED: Systematic disease management across a large population significantly improves patient outcomes, increases the productivity of a specialist service and could reduce healthcare costs compared with the current model of care.