3054 — Evaluating Vascular Access Process of Care Measures in Advanced Chronic Kidney Disease Patients
Lee T (Cincinnati VAMC), Lancaster E
(University of Cincinnati), Roy-Chaudhury P
(Cincinnati VAMC), Williams A
(Cincinnati VAMC), Thakar C
According to the 2009 United States Renal Data System the arteriovenous fistula (AVF) incident rate is only 15%. The Kidney Disease Quality Initiative guidelines for vascular access targets greater than 50% incident AVFs. The primary objective of this study was to evaluate achievement of specific “early” process of care measures in pre-dialysis vascular access care and associated estimated glomerular filtration rate (eGFR) when these benchmarks were reached.
We performed a retrospective study at the Cincinnati Veterans Administration (VA) identifying a cross-section of patients with an eGFR <= 30ml/min/1.73m2 from 2006 to 2007 and performed a 2-year follow-up. We identified 344 patients who met the above criteria. 98% were male, 76% white, 58% diabetics, and 37% had peripheral vascular disease. The mean age was 71 ± 11.9 with 67% of the study population >= 65 years of age.
288/344 (84%) patients had an initial nephrology consult and follow-up. 98/288 (34%) patients with nephrology follow-up had referral for pre-operative vein mapping, 69/288 (24%) patients had surgery referral, and 57/288 (20%) had pre-dialysis vascular access placement. Median eGFR at the time of pre-operative vein mapping referral and access placement was 15ml/min/1.73m2 and 11ml/min/1.73m2, respectively. Age < 65 (OR 1.75, p = 0.05 and OR 3.33, p = 0.0001) and black race (OR 2.66, p = 0.0008 and OR 4.22, p = < 0.0001) predicted vein mapping and surgery referral, respectively. Among patients who initiated dialysis (n = 87), only 26% commenced with AVF and 73% with catheters. In patients having a pre-emptive AVF placed and initiating dialysis, only eGFR > 15 at the time of surgery was associated with AVF use on first dialysis (OR 7.8, 95% CI 1.79-34.1, p = 0.0063).
Increasing the proportion and timing of referrals for pre-operative vein mapping, surgical referral, and placement of AVF at higher eGFRs, may play an important role to increasing incident AVF rates.
Future research should focus on patient-related factors and the patient-nephrologist interaction in vascular access decision-making process, as well as the role of multi-disciplinary pre-end stage renal disease care in improving our targets. Clearer recommendations are needed to guide providers when planning vascular access before dialysis in the elderly population.