“A Graft-free Hemodialysis Practice is Possible in a Community-Based Dialysis Unit

Despite High Patient Co-morbidities”

Authors: Nguyen, Vo, MD; Griffith, Chris, MD; and Robinson, Kevin.

AV fistula is the preferred hemodialysis access. A minority of US patients are dialyzed with an AVF. Since 1996 a team-oriented vascular access strategy has overcome the difficulties caused by patients high co-morbid factors to create only AVFs.

The overall purpose of this effort was to overcome the difficulties caused by patient’s high co-morbid factors to create only AVFs, minimize the use of catheters and eliminate the need of AV grafts.

This nephrologist and his access surgeons stopped revising failing AV grafts and instead converted them into AVF using the veins arterialized by prior AV grafts, placed only AVFs in new patients using Doppler vein mapping when physical examination vein mapping was not possible and maximized the use of upper arm veins and their transposition to a more superficial position if necessary.

Summary of Findings: A single nephrologist practice was reviewed with a current total of 62 dialysis patients (49 hemodialysis and 13 Peritoneal Dialysis). The charts of all hemodialysis patients were reviewed; age: 62, 2 (SD 13,6), 65% female, 73.5% diabetic mellitus, 63% peripheral vascular disease, 28% obese, 22% late referral.

A total of 48 AVF (97.7% of total patients) were created, of which 35.4% were radio-cephalic, 41.6% brachio-cephalic, 22.9% brachio-basilic and 32.6% were transposed. 10.4% had early AVF failure, 12.5% had late AVF failure, requiring revision. 10.8% had steal syndrome.

Of the 97.9% of patients with an AVF, only 87.7% have an adequately mature AVF that is of the date of the abstract (2/2001) successfully used for hemodialysis. 6 catheters are currently being used (12% of patient population), 10.2% of patient have both catheters and immature AVF. No AV grafts are used. 65% had Doppler vein mapping. (In this current practice, whenever possible, a PD catheter rather than a perm-catheter or graft is used until the AVF is mature).

Conclusions: Pre-existing co-morbid factors and late referral are not true obstacles to achieving an optimal AVF utilization goal. Strategies that can be used to achieve a 70-90% prevalent AVF rate in any hemodialysis patient population include:

· Team work with a nephrologist willing to lead the effort

· Dedicated, well-trained surgeons

· Long-term vascular access planning with pre-op Doppler vein mapping, if indicated

· Routine conversion of all AV grafts to AV fistulas

· Increased use of antecubital AVF with transposition as first choice in appropriate patients

· Use of a Nurse Vascular Access Coordinator to support and train staff in cannulation techniques, including buttonhole, to optimally use and preserve AVF

· Use of Peritoneal Dialysis as interim access rather than catheters

ASN 2001