dr Carlo Lomonte

U.O.C. di Nefrologia e Dialisi

Ente Ecclesiastico Ospedale Miulli

Acquaviva delle Fonti - Ba

Università La Sapienza

Scuola di Specializzazione in Nefrologia

Prof P. Menè

Meeting di Nefrololgia Interventistica

“L’Accesso Vascolare Impossibile” Roma 23 Marzo 2016

Il paziente anziano, evidenza e survey nazionale

The DOPPS (Dialysis Outcomes and Practice Pattern Study) is a prospective cohort

study of hemodialysis practices based on the collection of observational longitudinal data

3 Pazienti incidenti Pisoni, AJKD 2015

4 Pisoni, AJKD 2015 Pazienti prevalenti

www.dopps.org

68%

86%

www.dopps.org

68%

32%

Fistula First Change Concepts

The Change Concepts provide the roadmap to implement the KDOQI vascular access recommendations.

Interventional nephrology: a new

area of competency in nephrology

• Organization (The American Society of

Diagnostic and Interventional Nephrology – ASDIN,

was established on October 2000)

• Need (dysfunctional access was a major cause of

patient morbidity and mortality)

• Interest (nephrologists have been trained to

address all of the dialysis patient’s problems. The

exception was VA)

G Beathard. History of interventional nephrology in the US In Asif et al: Interventional Nephrology. McGraw-Hill 2012

• There is a substantial need for the establishment of Academic Dialysis Access Centers (ADACs)

• These centers would be essential for transforming IN into a distinct discipline within nephrology similar to transplant nephrology

Roy-Chaudhury et al, CJASN 2012

Academic Interventional Nephrology: A Model

for Training, Research, and Patient Care

Roy-Chaudhury et al, CJASN 2012

Roy-Chaudhury, CJASN 2012

• 35% surgeons

• 30% radiologists

• 25% nephrologists

• 10% anesthesiology and other specialties

vascular access costs

…e in Italia?

2000

Gruppo di Studio degli

Accessi Vascolari

Accessi vascolari prevalenti

FAV nativa

FAV protesica

CVC cuffiato

Censimento SIN 2004

4,6%

11,5%

83,9%

Who is the vascular access manager

Nephrologist 48.8%

Nephrologist and Vascular Surgeon 26.4%

Vascular Surgeon 18.4%

Others 6.4%

Courtesy by Decenzio Bonucchi

Chirurgo Vascolare

Nefrologo

Nefrologo + Chirurgo Vasc.

www.dopps.org

68%

• Lack of dedicated training

• Limited routine use of preoperative diagnostic imaging

• Accessibility of surgical resources for creating fistulas

• Patients characteristics

18

CJASN 2013

Annual Report of ERA-EDTA Registry 2012

• 65-74 years = 22%

• >75 years = 20%

Timely VA placement in the elderly

- Older patients lose renal function at slower rates than

youngers one (Vachharajani, CJASN 2011)

- The elderly patients may be more likely to die before

benefiting from an AVF (Hod, JASN 2015)

- The elderly patients with CKD should be referred later

to reduce the risk of creating an AVF that is never used

(Gomes, JASN 2013)

23 Hod et al, J Am Soc Nephrol 2015

VA in elderly patients: recent findings

• There is currently no general consensus as to the best

dialysis VA for elderly patients with ESRD

• The creation and use of a VA in elderly patients requires

the complex integration of patients, biological and surgical

factors because the VA type might be a key factor

influencing their survival

More vein, less plastic

Criteria for the ideal VA device

• Safe

• Reliable performance and adequate blood flow

• Durable long-term function

• Internal

• Free from complications

• Acceptable to the patients

• Simple to create

• Inexpensive to create and maintain

• Vein preservation is paramount in patients who can be identified as being in the early stage of CRF

• A culture of vein preservation has to be developed in renal and surgical units and among venipuncture nurses, anesthetists etc.

28 D Francis, Nephrology 2005

Detailed History

29

• Previous CVC (temporary or tunneled)

• Hospitalization for major events (trauma, ICU)

• Scars on the chest

• Previously failed VA

• Cardiac rhythm devices

• Swelling of the arm, shoulder, chest, brest, face

• Collaterals veins

Salman & Beathard, CJASN 2013

30

Physical examination (summary)

• Presence of a superficial vein (straight of at least 8-10 cm)

• Good arterial pulse (not diminished or absent)

• Negative Allen’s test (patent palmar arch)

• Difference < 10 mm Hg in blood pressure in 2 arms (normal)

Asif et al, J Nephrol 2007 32

31

The Necessity for Routine Pre-operative Ultrasound Mapping

Before Arteriovenous Fistula Creation: A Meta-analysis

Giorgiadis et al, Eur J Vasc Endovasc Surg. 2015

Randomized clinical trial of selective versus routine preoperative

duplex ultrasound imaging before arteriovenous fistula surgery.

Smith, Br J Surg. 2014

33

Elsharawy, J Vascular Access 2006

34

Three steps in order to increase the pool of eligible patients can be individualized:

1) process of care, which includes three fundamental items:

- the VA team

- early VA education

- timely VA surgical referral

2) preoperative evaluation

3) surgical strategy

Surgical strategy in elderly patients

- A recent meta-analysis examining studies from 2000 to

2012 reported a primary failure rate (defined as non

usable AVF for dialysis up to 6 months post creation) of

23 % (Al-Jaishi, AJKD 2014)

- AVF failure increases by 1% for every year above the

age of 67 years (Hod, Hemodial Int 2014)

- Patients over 65 years have a fistula failure rate double

that of younger patients (Lok, JASN 2006)

Primary failure

Clinical use of the score system

Lok, JASN 2006

38

» All patients with risk factors for central venous stenosis should have a venogram regardless of score

Lok, JASN 2006

39

40

Masengu, CKJ 2016

41

J Vasc Surg 2007

An Italian perspective

• AVF still remains the dialysis access with highest prevalence also in older patients, with an excellent survival rate (Venturelli et al JN 2013; Pirozzi et al JVA 2014)

• In Italy, among patients with > 4 months pre-ESRD care prior to starting chronic HD, 71% had AVF (DOPPS)

Ethier et al, NDT 2008

• …we believe that dialysis VA selection in the elderly should

be guided by patient’s preference and surgeon’s

experience, based on comprehensive, balanced and

unbiased information, adopting an individualized approach

that strives to achieve the best outcomes regardless of age.

Conclusion

Key messages

1. Renal replacement therapy in the elderly raises several issues.

2. The VA planning in the elderly is different from that in younger patients:

elderlies could be referred later to reduce the risk of creating an AVF that is

never used.

3. The elderly with limited life expectancy may be less likely to benefit from an

AVF first approach.

3. The patient’s preference for the type of VA should be taken into account.

4. We advice to adopt an individualized approach, regardless of age.

FAV PROSSIMALE

Revisione FAV PROTESICA

CATETERE long term

CVC TEMPORANEO

FAV PROTESICA

FAV “DISPERATA”

F.G.

- Il nefrologo ha sempre “titolo” per fare gli accessi! ?

Riabbocco FAV DISTALE

FAV DISTALE

Superficializzazione/Trasposizione V.nativi

CATETERE long term

FAV Prossimalizzata