Aims: This study reports long-term outcomes after endovascular salvage (EVS) for acute dialysis fistula/graft dysfunction. Methods: All patients presenting with acute fistula or graft dysfunction, excluding primary failures, referred for endovascular salvage were included in this single-centre prospective study. Results: Altogether, 410 procedures were carried out in 232 patients. Overall, the incidence of thrombosis/occlusion (per patient-year) was 0.12 for fistulae and 0.9 for grafts. The anatomical success rate for EVS was 94% for fistulae and 92% for grafts. Primary patency rates for fistulae at 1, 6, 12, 24 and 36 months were 82, 64, 44, 34 and 26%, respectively, whereas secondary patency rates were 88, 84, 74, 69 and 61%, respectively. Primary patency rates for grafts at 1, 6 and 12 months were 50, 14 and 8%. The overall rate of complications was 6% with no incidence of symptomatic pulmonary embolism. In a Cox regression model, upper-arm location of fistula (HR 1.9, p = 0.04, n = 144) was associated with lower primary patency, whereas the presence of thrombosis was associated lower primary (HR 1.9, p = 0.004, n = 144) and secondary patency (HR 3.7, p < 0.001, n = 144). Aspirin therapy was associated with longer primary patency (HR 0.6, p = 0.02, n = 144) and secondary patency (HR 0.58, p = 0.08, n = 144). Conclusion: EVS is effective but longer-term outcomes are poor. Presence of thrombosis portends poor fistula survival and strategies for prevention need attention. Balloon maceration, our preferred declotting technique, is safe and the most cost-effective method. Aspirin therapy for patients presenting with failure of fistulae deserves further investigation.

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage homebased dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.

Background and Aims Valvular heart disease (VHD) is highly prevalent in maintenance haemodialysis patients. This high prevalence is associated with poor outcomes and higher mortality [Samad et al., Journal of the American Heart Association, 6 (10), (2017)]. Previous large studies found VHD prevalence between 14% and 16% among prevalent haemodialysis patients [2018 USRDS Annual Data Report | Vol 2] [Hickson et al., Journal of the American College of Cardiology, 67(10), (2016)]. KDIGO consensus group identified several evidence gaps where research is necessary in order to improve our understanding of diagnosis and management of VHD in this population [Marwick et al., Kidney international, 96 (4), (2019)]. The aim of our study is to assess the burden of VHD in a large cohort of haemodialysis recipients in one center in the United Kingdom (UK). Method This is a retrospective cross-sectional evaluation of valvular heart disease in prevalent haemodialysis patients. Prevalent haemodialysis recipients were defined as patients established on haemodialysis for ≥ 3 months. Echocardiographic data was collected for all patients. Patients were considered to have VHD if they had significant aortic (AVD) or mitral valve disease (MVD) based on standard echocardiographic criteria. These valvular diseases are classified as mild, moderate or severe. Here, we report some descriptive statistics from our data. Results The study group includes 544 prevalent haemodialysis patients. Mean age was 62 years (SD 15.28), 40% females and 60% were males. Median dialysis vintage was 1.9 years (IQR 1, 3.2) [Range: 0.2, 10.2]. 14 % of patients received home-based hemodialysis and 86% received in-center dialysis. 30% of patients were actively awaiting a transplant. A total of 1155 echocardiography studies were reviewed. Of the 425 patients who had an echocardiogram; 34% (n=143) had evidence of VHD as defined above. Significant AVD was identified in 18% of patients (n=78). The dominant lesion was aortic regurgitation in 11%, and aortic stenosis in 7% of patients. 20% of patients (n=85) had significant MVD with mitral valve stenosis in 0.7% of patients (n=3) and mitral regurgitation in 18% of patients. 5% of patients had cardiothoracic intervention (n=21) for valvular heart disease, which included aortic valve replacement (n=9), transcatheter aortic valve implantation (TAVI) (n=9), and mitral valve replacement (n=3). Conclusion We found that at least one third (34%) of patients in this cohort had significant VHD- higher than the previously published figures. The numbers are likely to be higher, if echocardiogram information was available for all patients in the study. Timely echocardiographic studies and follow-up imaging for those with established disease are essential to identify patients with significant VHD, in order to establish impact of disease on both dialysis delivery and patient symptoms.

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