CORONADO, CALIF.– Clinicians have a ways to go before they reach the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative Guidelines for vascular access, a recent analysis of national data suggest.
Part of the challenge is because the incidence of renal disease continues to grow over time, Dr. Mark R. Nehler said at the annual meeting of the Western Vascular Society. “The elderly population is growing, and the need for access is growing,” said Dr. Nehler, chief of the section of vascular surgery and endovascular therapy and podiatry at the University of Colorado Anschutz Medical Campus, Aurora. “There’s also large geographic variation in how patients are being treated, and a large percentage of patients do not see a nephrologist before they’re put on dialysis.”
The 2010 targets set by the Kidney Disease Outcomes Quality Initiative Guidelines recommend that clinicians create an arteriovenous fistula (AVF) in 50% of new-onset and 67% of existing hemodialysis patients, respectively, and to use catheters in fewer than 10% of hemodialysis patients. “Over time, the recommendations have become catheter-last rather than fistula-first,” Dr. Nehler said.
According to 2014 incidence data Dr. Nehler presented from Fistula First, a coalition that focuses on increasing the use of AV fistulas and decreasing the use of tunneled dialysis catheters, clinicians are using AVFs in new-onset hemodialysis patients only 20% of the time, 75% are still using catheters, and 5% are using grafts. “If you look at the incidence data for access, we’re not meeting the guidelines,” Dr. Nehler commented. “A fair amount of them have fistulas maturing, but we’re nowhere close to the 50% of patients starting dialysis using a fistula.”
Prevalence data from Fistula First is more on target, with 64% of patients using an AVF, but 19% of patients are using a catheter for prevalent access, “so there’s still some work to be done, but these numbers continue to get better.” States doing a good job implementing the guidelines include Colorado, New Mexico, New Hampshire, Washington, and Utah. “Some of the worst performers are in the South and in the East,” Dr. Nehler said. “When you look at the types of patients that don’t do well with fistulas, you realize that it probably has as much to do with the types of patients [clinicians are] taking care of as it has to do with any particular skill set of the surgeons involved.”
He characterized the rate of fistula maturation as “fairly sobering, where you can see a failure rate of 40%-45%, based on results from randomized trials,” he said. “Failure rate has been associated with advanced age, vein size, forearm AVFs especially in diabetics and in nonwhite patients.”
Dr. Nehler reported having no financial disclosures.
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