Planning Optimal Dialysis Access for an Individual Patient
Planning Optimal Dialysis Access for an Individual Patient
Purpose of review Achieving functioning vascular access in hemodialysis patients remains challenging. Current guidelines recommend creating arteriovenous fistulas (AVFs) as the initial form of vascular access and are primarily based on outdated, observational data. Determining the optimal access for each individual patient is, therefore, of great interest.
Recent findings Multiple recent studies suggest that certain subgroups of patients may benefit from alternative forms of vascular access. In particular, the elderly and patients with limited life-expectancy may be less likely to benefit from an AVF first approach. These patients may be more likely to die before benefiting from an AVF and are more likely to experience primary failure of an AVF. If these factors are considered, arteriovenous grafts, and in some cases central venous catheters, become a valid alternative form of vascular access. Patients may also have strong opinions about each type of vascular access, leading to a preference for alternative forms of access.
Summary A patient-centered approach to the choice of dialysis access that incorporates a balance between recent evidence from the literature and patient preferences may be preferred to the current fistula first focus in vascular access choice.
Access planning for end-stage renal disease (ESRD) patients continues to be challenging. Current recommendations push for the creation of arteriovenous fistulas (AVFs) in most, if not all, patients starting hemodialysis. In contrast, patient-centered care, with a focus on individual patient preferences, is increasingly the goal of appropriate medical care. The inherent tension that can sometimes exist between practice guidelines and individualized patient care increases the need for well-designed studies assessing important clinical outcomes. In the case of hemodialysis vascular access, this means exploring how patient preferences, co-existing medical conditions, social and support situations, and the competing risk of mortality or change in renal replacement modality intersect with the type of dialysis access. This review attempts to describe the potential strategies for choosing the optimum dialysis access in an individual patient.
For the last decade, the Fistula First Breakthrough Initiative has largely been successful in increasing the number of prevalent hemodialysis patients receiving dialysis via an AVF. This recommendation is based on the data showing lower rates of infection, cost, and mortality in comparison to central venous catheters (CVCs), and, to a lesser degree, in comparison to arteriovenous grafts. To incentivize higher AVF rates, the Centers for Medicare and Medicaid Services will soon financially penalize dialysis centers that do not meet the set benchmark rates for AVF use. Underlying these recommendations is a body of evidence based largely on now outdated, observational studies, potentially making findings susceptible to selection or indication bias and not applicable to the current-day dialysis patients and practices. In an attempt to provide a more informed view, recent additional attention has been paid to how patient characteristics and preferences may affect the choice of dialysis access; in this review, we will focus specifically on hemodialysis vascular access. In addition, we will identify several key factors that a dialysis patient and provider should keep in mind while navigating from predialysis vascular access planning to maintenance dialysis.
Abstract and Introduction
Abstract
Purpose of review Achieving functioning vascular access in hemodialysis patients remains challenging. Current guidelines recommend creating arteriovenous fistulas (AVFs) as the initial form of vascular access and are primarily based on outdated, observational data. Determining the optimal access for each individual patient is, therefore, of great interest.
Recent findings Multiple recent studies suggest that certain subgroups of patients may benefit from alternative forms of vascular access. In particular, the elderly and patients with limited life-expectancy may be less likely to benefit from an AVF first approach. These patients may be more likely to die before benefiting from an AVF and are more likely to experience primary failure of an AVF. If these factors are considered, arteriovenous grafts, and in some cases central venous catheters, become a valid alternative form of vascular access. Patients may also have strong opinions about each type of vascular access, leading to a preference for alternative forms of access.
Summary A patient-centered approach to the choice of dialysis access that incorporates a balance between recent evidence from the literature and patient preferences may be preferred to the current fistula first focus in vascular access choice.
Introduction
Access planning for end-stage renal disease (ESRD) patients continues to be challenging. Current recommendations push for the creation of arteriovenous fistulas (AVFs) in most, if not all, patients starting hemodialysis. In contrast, patient-centered care, with a focus on individual patient preferences, is increasingly the goal of appropriate medical care. The inherent tension that can sometimes exist between practice guidelines and individualized patient care increases the need for well-designed studies assessing important clinical outcomes. In the case of hemodialysis vascular access, this means exploring how patient preferences, co-existing medical conditions, social and support situations, and the competing risk of mortality or change in renal replacement modality intersect with the type of dialysis access. This review attempts to describe the potential strategies for choosing the optimum dialysis access in an individual patient.
For the last decade, the Fistula First Breakthrough Initiative has largely been successful in increasing the number of prevalent hemodialysis patients receiving dialysis via an AVF. This recommendation is based on the data showing lower rates of infection, cost, and mortality in comparison to central venous catheters (CVCs), and, to a lesser degree, in comparison to arteriovenous grafts. To incentivize higher AVF rates, the Centers for Medicare and Medicaid Services will soon financially penalize dialysis centers that do not meet the set benchmark rates for AVF use. Underlying these recommendations is a body of evidence based largely on now outdated, observational studies, potentially making findings susceptible to selection or indication bias and not applicable to the current-day dialysis patients and practices. In an attempt to provide a more informed view, recent additional attention has been paid to how patient characteristics and preferences may affect the choice of dialysis access; in this review, we will focus specifically on hemodialysis vascular access. In addition, we will identify several key factors that a dialysis patient and provider should keep in mind while navigating from predialysis vascular access planning to maintenance dialysis.