American Society of Diagnostic and Interventional Nephrology Section Editor: Stephen Ash: Stenosis Surveillance of Hemodialysis Grafts by Duplex Ultrasound Reduces Hospitalizations and Cost of Care

Abstract

Most recent randomized controlled trials (RCTs) have found that hemodialysis graft surveillance combined with preemptive correction of stenosis does not prolong graft survival. Nevertheless, such programs may be justified if they reduce other adverse outcomes or decrease the cost of care. This study tested this hypothesis by applying a secondary analysis to our original RCT. This study of 101 patients evaluated correction of stenosis based upon blood flow (Q) and stenosis surveillance. Patients were randomly assigned to control, flow, or stenosis groups, and were followed for up to 28 months. Q was measured monthly by ultrasound dilution; stenosis was measured quarterly by duplex ultrasound. Stenosis of 50% was corrected by percutaneous transluminal angioplasty (PTA) after referral for angiography. Referral criteria were: control group, clinical criteria; flow group, Q < 600 ml/min or clinical criteria; stenosis group, stenosis > 50% or clinical criteria. We compared access-related hospitalizations and cost of care, and use of central venous dialysis catheters (CVCs), among the three groups. Hospitalization rates were higher in the control and flow groups than in the stenosis group (0.50, 0.57, 0.18/patient-year, respectively [p < 0.01]), and hospitalization costs were lowest in the stenosis group (p = 0.026). The stenosis group had a trend toward lowest CVC rates (0.44, 0.32, 0.20/patient-year, respectively [p = 0.20]). The costs of care were higher in the control and flow groups than in the stenosis group (dollar 3727, dollar 4839, dollar 3306/patient-year, respectively [p = 0.015]). The costs of stenosis (dollar 142/patient-year) and Q (dollar 279/patient-year) measurements were minimal compared to the total cost of access-related care. In conclusion, stenosis surveillance by duplex ultrasound combined with preemptive correction yielded reduced hospitalization rates and costs, reduced total cost of access-related care, and a trend of reduced CVC rates. In contrast, flow surveillance did not yield a significant benefit. Stenosis surveillance provides important benefits that may justify application of such programs.

The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access

“…Furthermore, although access survival was no different in members of the group who underwent surveillance, it is possible that their lower incidence of thrombosis may translate into a reduction in access-related costs and hospitalizations, as demonstrated in a reanalysis of a small study by Dossabhoy et al 80 and by a quality improvement project conducted by Wijnen et al 81 In the latter study, flow surveillance produced a 32.5% reduction in the overall cost of access care. Savings occurred chiefly in the prosthetic access group and resulted from reduction in the number of invasive procedures, central catheters, and hospitalizations.…”

Maintenance of Hemodialysis Arteriovenous Fistulas by an Interventional Strategy

“…20 There is evidence that stenosis surveillance by DUS combined with preemptive correction, regardless of other criteria, may be superior to an invasive strategy based only on clinical or flow criteria. 21 Two recent clinical trials reported different results using DUS screening followed by PTA in prosthetic grafts for HD access. Malik et al 7 showed significantly longer prosthetic graft patency with DUS performed every 3 months, whereas Robbin et al 8 reported no significant decrease of graft failure rates or thrombosis with DUS performed every 4 months.…”

Outcomes of Endovascular Intervention for Salvage of Failing Hemodialysis Access

“…Research has shown that regular surveillance may lead to improved quality of life for dialysis patients, 15) possibly from a reduction in the quantity of time spent in hospitals due to complications of access failure. 16) This benefit, however, has to be viewed in the context of unnecessarily exposing patients to increased numbers of salvage interventions as a consequence of routine surveillance. 17,18) Importantly, there is substantial evidence that regular surveillance of AVGs may not decrease the risk of graft thrombosis, 19) nor prolong the time to graft abandonement.…”