Delay in Permanent Vascular Access Formation and Referral to a Nephrologist in Incident Hemodialysis Patients: A Single Center Experience

Abstract

Objective: This study assessed the factors associated with delayed referral to a nephrologist and delay in formation of a permanent vascular access in incident hemodialysis (HD) patients. Methods: This prospective cross-sectional study was conducted from February 2021 to July 2021 on end stage renal disease (ESRD) patients receiving maintenance hemodialysis (MHD) at our center. Data were collected at the bedside during the HD session about a referral to a nephrologist, about when they were asked for permanent vascular access formation and the reason for the delay in its formation. Results: Out of 296 patients recruited in our study, 168 (56.8%) were male and 128 (43.2) were female. The mean age was 53.5±15 years (minimum of 19 years and maximum of 90 years). The most common reason for refusal of making permanent vascular access [arterio-venous fistula (AVF) or arterio-venous graft (AVG)] was fear of pain in our patients 65 (43.3%) followed by the denial of the disease 32 (21.3%). Among the study subjects, 231 (78%) patients were referred to the nephrologist immediately or within one month of their diagnosis. Some 152 (51.4%) of the patients were not in favor of making AVF whereas 151 (51%) refused for starting HD, hence most of our patients 181 (61.1%) initiated HD in emergency by a central venous catheter (CVC). Conclusion: Early referral should be done by primary care physicians (PCPs) for the timely management of CKD patients. As CKD is a progressive disease, it requires special attention by a nephrologist for adjustment of patient’s medications, timely follow-up, counseling, the early formation of AVF for HD, and planning for renal transplant. In our study, the majority of our patients initiated their HD via CVC because of the delayed visit to a nephrologist. Most patients were asked for AVF formation on the same day of presentation to our nephrology unit as they had advanced CKD (Stage 5) 134 (51.4%). Most patients in our study delayed AVF formation 152 (51.4%). With timely referral to a nephrologist, the nephrologist will be able to do better and repeated counseling about the disease, its progression, and the need for permanent vascular access for initiation of HD while patients and their families will get more time to make decisions.

Arterio-Venous Fistula Creation for Hemodialysis. What Is Happening in Bulgaria?

“…Only 8% of patients developed distal latero-terminal radiocephalic fistula (DLTRC) -Figure 1. native fistula [6]. Careful preoperative clinical and instrumental evaluation is required to decide both the site and type of anastomosis.…”

Beyond Blood Glucose and Blood Pressure Control in Type 2 Diabetes: Alternative Management Strategies to Prevent the Development and Progression of CKD

“…The 2022 ADA guidelines and KDIGO CKD Working Group recommend that patients with advanced kidney disease (eGFR < 30 mL/min/1.73 m 2 ) also be referred to a kidney specialist. 61 , 62 …”

“…The 2022 ADA guidelines and KDIGO CKD Working Group recommend that patients with advanced kidney disease (eGFR < 30 mL/min/1.73 m 2 ) also be referred to a kidney specialist. 61,62 The ADA notes that, despite recommendations for early referral, there are additional factors that influence the decision for primary care clinicians to refer patients, which may not always make early referrals feasible. 63 Study results from an US academic healthcare system found that only 45.4% of patients actively visiting their primary care clinicians are referred to a nephrologist, but the study did not specify whether patients who were referred had an eGFR < 30 mL/min/1.73 m 2 .…”