vascular access in australia new zealand: some answers ... 2011/… · dnt march 2011. outline ......
TRANSCRIPT
Vascular Access In Australia & New Zealand:
Some Answers & Questions
Assoc Prof Kevan PolkinghorneMonash Medical Centre
DNT March 2011
Outline
• Incident VA outcomes in ANZDATA– Overall– Centre Data
• Why Do We Fail To Commence Patients With AVF?– Data from CARI implementation project
Prevalent Line Use vs. Unit Size Australia
Why Do We Fail To Commence Patients With AVF?
Is It Rocket Science?
It’s time to face reality, my friends. We’re not exactly rocket scientists.
Is It Rocket Science?
Why Do We Fail To Commence Patients With AVF?
• 1. Individual Patient Factors ‐Morbidity
• 2. Physician Based Factors
• 3. “Patient Factors” – Traits/Cultural Factors
Why Do We Fail To Commence Patients With AVF?
• 1. Individual Patient Factors
• A number of individual patient factors are associated with catheter use
• Are largely un‐modifiable factors
Predictors Of Line Use: Australia
Predictors Of Line Use: New Zealand
Why Do We Fail To Commence Patients With AVF?
• 1. Individual Patient Factors
• A number of individual patient factors are associated with catheter use
• Are largely un‐modifiable factors
• Primary Failure
Primary Failure?• High primary failure rates often used to explain low AVF rate at commencement
Primary Failure?• Definition:
– Varies enormously in the literature
• Standard definition:
• Failure of the Fistula before ever being used for dialysis
• Majority of the literature from 1980’s – 1990’s
Primary Failure?
Rooijens etal Eur J Vasc Endovasc Surg 28, 583–589 (2004)
Primary AVF: US Based Study
Primary Failure 25%
1/3 RC AVF
2/3 BC AVF
Biuckians et al J Vasc Surg: 2008 vol. 47 (2) pp. 415-21;
Previous Failed AVF
Lee et al JASN 2007; 18 (6):1936-41
Previous Failed AVF
Lee et al JASN 2007; 18 (6):1936-41
Primary Failure: Centre Effect?
Huijbregts et al J Vasc Surg 2007 vol. 45: 962-7
DOPPS II Data: “Primary Failure”
Saran et al Ann Surg 2008 vol. 247 (5) pp. 885-91
“Primary failure”: the occurrence of a first intervention for possible access salvage
Why Do We Fail To Commence Patients With AVF?
• Primary Failure a factor but may not be the major factor– Favoured Trial
• Two Groups of Patients who commence with a catheter:– Those with no AVF– Those with an AVF that’s not usable
Majority Have No AVF?
• CARI Project:
• Of the 189 patients with who commenced with a catheter– 142 (76%) had no AVF/AVG in place– 88/142 (62%) were not referred late– Of the 30 with an AVF in situ, 12 had access thrombosis (primary failure)
Why Do We Fail To Commence Patients With AVF?
• 1. Individual Patient Factors ‐Morbidity
• 2. Physician Based Factors
• 3. “Patient Factors” – Traits/Cultural Factors
Why Do We Fail To Commence Patients With AVF?
• 2. Physician Based Factors
• Timing of AVF Placement
Timing of AVF Placement?
Lopez-Vargas et al AJKD In Press 2011
Timing of AVF Placement?
Lopez-Vargas et al AJKD In Press 2011
Timing of AVF Placement?
Ethier et al NDT 2008 vol. 23 (10) pp. 3219-26
a Adjusted for patient age, sex, late referral, cause of ESKD, cigarette smoking, peripheral vascular disease, presentation type and pre-dialysis education.
CARI Project: Timing of AVF Creation
Why Do We Fail To Commence Patients With AVF?
• 1. Individual Patient Factors ‐Morbidity
• 2. Physician Based Factors
• 3. “Patient Factors” – Traits/Cultural Factors– Little Data– Patient Education
• Assessed 490 incident haemodialysis patients with the Chronic Hemodialysis Knowledge Survey– The Chronic Hemodialysis Knowledge Survey (CHeKS) evaluates
patient knowledge about important issues in CHD care including dialysis adequacy, nutrition, anemia, access care, medications, and safety.
– The scale included 23 multiple‐choice items, with only one correct response
Patient Education
CARI Project: Patient Education
CARI Project: Patient Education
a Adjusted for patient age, sex, late referral, cause of ESKD, cigarette smoking, peripheral vascular disease, presentation type and pre-dialysis education.
CARI Project: Patient Education
a Adjusted for patient age, sex, late referral, cause of ESKD, cigarette smoking, peripheral vascular disease, presentation type and pre-dialysis education.
Formalised Predialysis Pathway?
Dropped The Ball?
Summary: What is Needed?
• Co‐ordinated effort to reduce catheter use• Early patient & family education is key• Earlier AVF placement – ?Formalised “Pre End Stage Pathway”
• ?? Use AVG in high risk patients to reduce catheter exposure – needs an RCT
• All units need to collect their own data & review it regularly.
• ANZDATA Registry• Phil Clayton/Stephen McDonald/Mark Marshall
• Pamela Lopez Vargus• CARI Implementation Study Group
– Steering committee– Study centres
Acknowledgements
