The Influence of Age on the Likelihood of Catheter-Free Fistula Use in Hemodialysis Patients

Ladak, Farah; Ravani, Pietro; Oliver, Matthew J.; Kamar, Fareed; Clarke, Alix; Hiremath, Swapnil; MacRae, Jennifer M.; Blake, Peter G.; Moist, Louise; Garg, Amit X.; Lam, Ngan N.; Dumaine, Chance S.; Quinn, Robert R.

doi:10.1177/2054358119861943

Cited by 8 publications

(10 citation statements)

References 23 publications

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“…The sample size estimate is based on the primary hypothesis that, by the end of the study, the patients in the AVG group will have more CVC-free days than patients in AVF group. Based on our pilot study [ 19 , 20 , 30 ], the average rate for CVC-free days was 15/100 patient-days among study patients who underwent AVF placement; similar or higher rate of CVC-free days was reported in other studies [ 31 – 33 ]. For this study, sample size calculations are based on two-sided tests with 5% type 1 error rate and a conservative estimate of 25% drop-out rate.…”

Section: Methodssupporting

confidence: 70%

Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial

et al. 2023

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Background Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access—fistula (AVF) or graft (AVG)—to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers. Methods This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections—defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients’ experiences with vascular access care between the two treatment groups. Discussion In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making. Trial registration : This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).

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Section: Methodssupporting

confidence: 70%

Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial

et al. 2023

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“…16 Comparably, evaluating patients who were submitted exclusively to AVF, only 57% of these lead to catheter independence and, even with multiple attempts, only 40% of the time on hemodialysis is catheter-free. 17 However, these AVF weaknesses, do not totally overcome their long-term benefits, because a mature and functional AVF has less need for interventions and infections compared to AVGs, and probably benefits the majority of patients. Therefore, the criticism of the indication of AVF as the best access always lies in its placement in patients with characteristics that are not favorable to the maturation of AVFs, such as small arteries and veins, and in the increase in exposure to catheters due to the high chance of primary and maturation failures.…”

Section: Ffbi Concepts and Impactmentioning

confidence: 99%

“…26 However, other recent retrospective studies suggests AVF patency is not affected by age. 16,17,25 A retrospective assessment in the elderly showed similar survival among patients over 80 years of age who had an AVG or AVF as their first pre-dialysis access, with worse survival in those starting with a catheter. 27 These findings were repeated in a recent analysis, with similar patency outcomes between AVF and AVG in the group over 80 years old, but with an advantage for AVFs, including patient survival, in the groups from 65 to 79 years of age.…”

Section: Access In the Elderlymentioning

confidence: 99%

Is the Fistula First Approach still valid?

Franco¹

2021

Braz. J. Nephrol.

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The Fistula First Breakthrough Initiative, founded in 2003, was responsible for changing the access profile in the United States, increasing the prevalence of arteriovenous fistulas (AVFs) by 50% and reducing that of arteriovenous grafts (AVGs). However, the concept that AVFs are always the best access for all patients has been challenged. Discussion points are: (1) the questionable survival benefit of AVFs over AVGs, if one takes into account the high rates of primary AVF failure; (2) the potential benefits of using AVGs for greater primary success; and (3) the questionable benefit of AVFs over AVGs in patients with shorter survival, such as the elderly. The high rate of primary failure and maturation procedures leads to prolonged use of catheters, and it is one of the weaknesses of the fistula first strategy. AVGs proved to be better than AVFs as a second access after the failure of a first AVF, and in patients with non-ideal vessels, with greater primary success and reduced catheter times. AVGs appear to have a similar survival to AVFs in patients older than 80 years, with less primary failures and interventions to promote maturation. The most recent KDOQUI guidelines suggest an individualized approach in access planning, taking into account life expectancy, comorbidities and individual vascular characteristics, with the aim of chosing adequate access for the right patient, at the right time, for the right reasons.

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“…Data were collected using the Dialysis Measurement Analysis and Reporting (DMAR™) System that has been used previously in several Canadian provinces and during a pilot project conducted in the Calgary Zone between 2013 and 2014. 2 , 9 , 12 - 20 Baseline information about pre-dialysis care, the circumstances surrounding the initiation of dialysis (including the indication for starting and the presence or absence of symptoms and signs), baseline demographics, comorbidities, and laboratory information were recorded. We also captured a structured assessment for PD eligibility including contraindications to therapy, medical, social, and psychological barriers to home dialysis, patients’ living situations, details of the support available to them in their homes, whether they were ultimately deemed eligible for PD by the multidisciplinary team, whether they were offered PD as a treatment option, chose PD, and ultimately received it.…”

Section: Methodsmentioning

confidence: 99%

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis

Quinn

Farah

Schwartz

et al. 2021

Can J Kidney Health Dis

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Background: Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low. Objectives: The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed. Design: The START Project was a comprehensive, province-wide quality improvement intervention. Setting: The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province. Patients: The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria. Measurements: We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died. Methods: START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the “Plan-Do-Study-Act Cycle”). Results: Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level. Limitations: The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult. Conclusions: The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.

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The Influence of Age on the Likelihood of Catheter-Free Fistula Use in Hemodialysis Patients

Cited by 8 publications

References 23 publications

Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial

Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial

Is the Fistula First Approach still valid?

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis

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