Pre-dialysis AVF Placement for ESRD Patients: Valuable

John C. Eun, PGY-6University of Colorado DenverGrand Rounds Presentation

11/14/11

Outline

• Magnitude of problem• History• Guidelines• Problems• Barriers• Data• Conclusions

Incidence

• Over 29 million people in the U.S. have CKD1

• 571, 414 patients with ESRD in U.S (2009)2

• 116,395 new patients diagnosed with ESRD2

• $42.5 Billion spent on ESRD patient care2

– $29 Billion through medicare2

• 1.3% of pts on medicare have ESRD but account for 8.1% of spending2

– $82,285 spent per person/year for HD2

1) http://www.kidney.org/kidneyDisease/2) United States Renal Data System 2011--http://www.usrds.org/

Incidence

http://www.kidney.org/professionals/kdoqi/guidelines_ckd/Gif_File/kck_t10.gif

History1

• 1896: Jaboulay and Briau– End to end arterial anastomosis– Alexis Carrel introduced the three-point end-to-end

and a side-to-side anastomosis• Won the Nobel Prize in 1912

1) Konner, K. History of vascular access for haemodialysis. Nephrol Dial Transplant 2005

History1

• 1924: Georg Haas performed first HD treatment in humans using glass cannulas from radial artery to cubital vein.

• 1943: Willem Kolff used venipuncture needles from femoral artery to vein.

• 1960, March 9th: Clyde Shields was given a AV shunt made of two thin-walled Teflon cannulas (developed by Quinton, Dillard, and Scribner) in the radial artery and the cephalic vein connected by a Teflon bypass tube. Survived 11 years.

1) Konner, K. History of vascular access for haemodialysis. Nephrol Dial Transplant 2005

Blagg CR. Belding Hibbard Scribner—better known as Scrib. Clinc J Am Soc Nephrol 2010.

History1

• Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med Nov 17, 1966—results of the first 14 patients– Kenneth Appell was the surgeon who performed the first AV fistula in 1965 (side-

to-side radial artery to cephallic vein)

1) Konner, K. History of vascular access for haemodialysis. Nephrol Dial Transplant 2005

http://kennethappellmd2.blogspot.com/

Clinical Practice Guidelines for HD Access1

• Patients with a GFR less than 30 mL/min/1.73 m2 (CKD stage 4) should be educated in all modalities of kidney replacement therapy options, so that timely referral can be made to the appropriate modality and placement of a permanent dialysis access, if necessary.

• In pts with CKD stage 4 or 5, fore-arm and upper-arm veins suitable for placement of vascular access should not be used for venipuncture.

• Patients should have a functional permanent access at the initiation of dialysis therapy.– A fistula should be placed at least 6 months before the anticipated

start date of HD treatments. This timing allows for access evaluation and additional time for revision to ensure a working fistula is available at initiation of dialysis therapy.

1) Clinical practice guidelines for vacular access. Am J Kidney Dis 48 (Suppl. 1) 2006

The Problem1

• AVF– Provide higher flow rates than CVC

• Can reduce the effective dialyzer clearance– Lower rates

• Infection– 2nd leading cause of mortality

• Central venous stenosis– Higher patency rates

• ¼ of hospital admissions are due to vascular access issues• Despite this 2/3 of HD pts use a CVC at the initiation of HD

– Fewer than 15% begin HD with an AVF– AVF increases with time on dialysis– 1/3 still do not have an AVF by 6 months of initiation of HD

1) Astor BC, Eustace JA, et al. Type of vascular access and survival among incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study. J Am Soc Nephrol 2005

Barriers1

• Decision to make and AVF is complex and unique– Vaccination: does not have clearly documented proven public health benefits beyond the individual– AAA: Not a potentially life-saving procedure– Life insurance-will only accrue benefits if the event occurs

• Risk of unnecessary surgery:– Major limitations when using fixed eGFR cut points to patients

• Older pts experience slower loss of eGFR and lower incidence of ESRD

1) O’Hare AM, Allon M, Kaufman JS. Wheter and when to refer patients for predialysis AV fistula creation: Complex decision making in the face of uncertainty. Seminars in Dialysis 2010

Central Vein Stenosis1

• Up to 25% dysfunctional AVF have CVS– Almost all with a h/o prior SCV catheterization– Subclavian catheters up to 42% stenosis vs. 10% IJ

• Mostly asymptomatic – Most commonly presents as extremity and breast edema, pain,

inadequate dialysis and AVF failure• Sx may only present after AVF creation

– Thrombosis of AVF– Venous thrombosis– SVC sx

1) Agarwal AK, Bhairavi BM, Haddad NJ. Central vein stenosis: A nephrologist’s perspective. Semiinars in Dialysis 2007.

• Retrospective study• 7403 pts from Multiple HD sites in SC, NC, GA• April 1998-January 1999• Uncuffed 3%, Cuffed 11%, Graft 66%, AVF 20%• 672 deaths (9.1 %)• 103 (15.3%) attributed to infection

Pastan S, et al. Kidney International 2002

* * *

*

* p<0.001 vs. Fistula

Pastan et al.• CVC had higher risk of all-cause death• CVC had higher risk of death associated with infection• Increase in death still seen even when adjusted for renal

function, HD length, and comorbidities

• Retrospective review on Medicare pts on HD– 66,595 pts (1995-1997)– 67 years and older– Looked at age, sex, race, diabetic status, BMI, biochemical data– Used statistical analyses to determine hazard regression for risk for death at 90

days, 6 months, 1 year after HD initiation and survival curves– 37,826 patients (56.8%) had CVC– 18,808 patients (28.2%) and synthetic grafts– 3,543 patients (5.3%) had autologous vein grafts– 6,418 patients (9.6%) had AVF

Xue JL, et al. Am J of Kidney Diseases 2003

• National, prospective study– Oct 1995-June 1998– 616 pts from 79 dialysis clinics

• HD as initial renal replacement therapy

– 410 (66.6%) CVC– 121 (19.6%) AVG– 85 (13.8%) AVF

• Median F/U 27 months– 195 deaths (31%)

Astor BC, Eustace JA, et al. Type of vascular access and survival among incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study. J Am Soc Nephrol 2005

*

#

# P=0.05 vs. Cath* P=0.008 vs. Cath

Astor BC, Eustace JA, et al. Type of vascular access and survival among incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study. J Am Soc Nephrol 2005

• Fistula First Initiative• 2005 by The Center for Medicare and Medicaid Services along with consortium

of organizations• Goal of 66% AVF-based access for HD patients

• A study to project the financial impact of meeting that goal

Schon D, et al. Clinc J Am Soc Nephrol 2007

Schon D, et al. Clinc J Am Soc Nephrol 2007

Costs• $9030 savings for in access-attributed expenditures per pt lifetime• $843 million saved for the entire cohort• 3% per lifetime costs

Schon D, et al. Clinc J Am Soc Nephrol 2007

•Derived from summary data from the Vascular Access DOQI from 1997

Conclusions• AVF provides less mortality

– Less complications– Less infections

• AVF less cost• AVF better longer term solution

Thank You