Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Services Research & Development

Veterans Crisis Line Badge
Go to the ORD website
Go to the QUERI website

2011 HSR&D National Meeting Abstract

Printable View

2011 National Meeting

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 (Cincinnati VAMC)

Objectives:
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.

Methods:
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.

Results:
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).

Implications:
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.

Impacts:
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.


Questions about the HSR&D website? Email the Web Team.

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.