• Users Online: 110
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 40-44

The practiced pattern of vascular access used in hemodialysis: A cross-sectional study


1 Alzawia Kidney Hospital and Faculty of Medicine, Alzawia University, Alzawia, Libya
2 Alzawia Kidney Hospital, Alzawia, Libya
3 Sabratha Teaching Hospital, Sabratha and Faculty of Medicine, Alzawia University, Alzawia, Libya

Date of Submission23-Sep-2021
Date of Acceptance26-Oct-2022
Date of Web Publication02-Jan-2023

Correspondence Address:
Dr. Rodaba Ahmed Bitrou
Department of Medicine, University of Zawia, Azzawiyah Kidney Hospital, AZ-Zawiyah
Libya
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ljms.ljms_56_21

Rights and Permissions
  Abstract 


Background: The incidence of end-stage renal disease (ESRD) is increasing considerably worldwide; moreover, most of the patients start their therapy by hemodialysis (HD). Arteriovenous fistula (AVF) is the best type of vascular access for use in such therapy, due to its decreased rate of complications, followed by arteriovenous graft (AVG) and finally, central venous catheters, which are associated with, increased mortality and morbidity. In this study, we aim to find out the proportion of the current to initial vascular access used, the timing of creating permanent access, and any complications experienced. Patients and Methods: A cross-sectional study was conducted on two hundred eighteen patients currently on regular hemodialysis program. Their records were reviewed and the data was analyzed for vascular accesses type used at the start of hemodialysis and at the current time, the timing of the creation of permanent access, and the complications occurred. Data collected were statistically analyzed using IBM-SPSS statistics software Inc. Chicago, IL, USA. Results: Out-of-the 218 patients on hemodialysis, 193 patients (88.5%) started hemodialysis via Central venous catheters (CVC), 23 patients (10.5%) had an arterio-venous fistula (AVF), and only two patients (0.9%) used tunneled CVC, while no one has AV-graft. Currently, 82.1% of patients have AVF, 7.8% have chronic CVC, 5.9% have acute CVC and only 4.1% have AV-Graft, Many complications are noted in all types of access with different percentages of occurrence. Conclusion: We concluded that although a high percentage of patients have AVF, still pre-emptive AVF counts very low percentage, serious complications are still happening and we recommend the establishment of joined pre-dialysis clinic with surgeons and psychologists in each dialysis center.

Keywords: End-stage renal disease, hemodialysis, Libya, vascular access


How to cite this article:
Bitrou RA, Shaibani B, Ahmed HS, Ayad K. The practiced pattern of vascular access used in hemodialysis: A cross-sectional study. Libyan J Med Sci 2022;6:40-4

How to cite this URL:
Bitrou RA, Shaibani B, Ahmed HS, Ayad K. The practiced pattern of vascular access used in hemodialysis: A cross-sectional study. Libyan J Med Sci [serial online] 2022 [cited 2023 Feb 7];6:40-4. Available from: https://www.ljmsonline.com/text.asp?2022/6/2/40/366082




  Introduction Top


The incidence of end-stage renal disease (ESRD) is increasing considerably in the past few years; the incidence in 2008 in the USA was 112,476 compared to 120,435 in 2014. However, more than 87% of the incident patients start their therapy with hemodialysis (HD).[1],[2]

Libya is a sparsely populated medium-developed country, but it has a high prevalence of risk factors for chronic kidney diseases (CKD) such as diabetes, hypertension, and obesity,[3],[4],[5] where the societal, economic, and environmental transformation has contributed to people tending to adopt a sedentary life that further burdens the overall health burdens of the country.[6] Libya was among the first countries in the region to establish free access to maintenance dialysis therapy for patients with ESRD.[7] Although vascular surgery improved in the last few years, it is still lacking and does not meet the needs for access creation and management of the complications.

Vascular access type is one of the most important factors that affect the health outcomes of HD patients. Central venous catheters (CVC), arteriovenous fistula (AVF), and arteriovenous grafts (AVG) are different types of accesses that can be used for HD. However, many factors will influence the location and the type of access that will be used, for example, the patient's arterial, venous and cardiorespiratory systems, other clinical and socioeconomic factors, and duration on HD.[8],[9]

Reports from middle- and low-income countries show a common theme: a high rate of AVF creation but typically only after initiating dialysis with a CVC (90%–95%).[10],[11] Factors associated with improved outcomes in these countries include early referral and a multidisciplinary approach.[12],[13]

This study aims to work out the current situation of practice at a Libyan dialysis facility and to look into the complication of each type of vascular accesses in use for HD.


  Patients and Methods Top


A cross-sectional study was conducted during the period from November 2020 till January 2021, on 218 patients on chronic hemodialysis; analyzing their file records for types of vascular accesses used at the start of hemodialysis until the creation of chronic access along with records on timing and complications that happened at the study period. Data collected were statistically analyzed using SPSS software. Patients had to meet the following eligibility criteria for inclusion in the study: patient known to have ESRD on regular HD in the included center, age ≥18 years old. Patients who did not meet the inclusion criteria or those who refused to participate were excluded from the study. All patients were on regular HD, twice or thrice weekly. Vascular access type data were collected with specific data relating to the anatomical location of vascular access, and duration of access use, and to avoid the possibility of confusing of dialysis access types, a physical examination of each patient was done to assure the proper vascular access was recorded.


  Results Top


The median age was 49 years (18-92 years) male gender predominates the population of the study group with 64% of patients; diabetic nephropathy was the main cause of CKD (33.9%) followed by hypertension (20.6%). Mean BMI is 26 ranging from 16-54, and the mean duration of hemodialysis was five years (ranging from 6 months to 21-years). Baseline demographic and other characteristics of patients are presented in [Table 1], [Figure 1].
Figure 1: Pattern of vascular access at start of hemodialysis and at current time

Click here to view
Table 1: Demographic data

Click here to view


193/218 patients on hemodialysis (88.5%) started hemodialysis via Central venous catheters (CVC), 23/218 patients (10.5%) had an arterio-venous fistula (AVF), and only 2/218 patients (0.9%) used tunneled CVC; none has AV-graft.

Currently, 82.1% of patients have AVF, 7.8% have chronic CVC, 15.9% have acute CVC and only 4.1% have AV-Graft as shown in [Table 2].
Table 2: Type of access at start of hemodialysis and at current time

Click here to view


Early AVF creation before the start of hemodialysis was observed only in 10.5% of patients, while later creation after starting of chronic hemodialysis therapy was observed in 45% of patients after one to two months, while 35% of patients have it created after 3-4 months [Table 3].
Table 3: Patients with tunneled central venous catheters as chronic access for hemodialysis

Click here to view


Chronic vascular catheters were grouped into four subgroups as seen in [Table 3]; no AVF nor AVG group counts 4 patients (23.5%), immature AVF group with 6 patients (35.3%), one previous failed AVF or AVG group with 3 patients (17.6%), and more than one previous attempt of AVF or AVG group with 4 patients (23.5%) as shown in [Table 4].
Table 4: Timing of arteriovenous fistulas creation

Click here to view


Many complications were recorded in all types of access with different percentage of occurrence as follows: Thrombosis in 22% of patients, infection in 13.8%, central venous stenosis in 12.4%, aneurysm in 9.2%, hematoma in 6.9%, and steal syndrome in 1.8%, as shown in [Figure 2].
Figure 2: Complication

Click here to view


We observed that more vascular access complications occurred in Diabetic patients and female gender.


  Discussion Top


The choice of vascular access should be individualized according to the specific patient characteristics. The primary goal should be a distal autogenous AVF in the non-dominant arm, created three to six months before the expected start of hemodialysis.[14],[15],[16] This would allow time for maturation and even intervention in the event the fistula fails to mature adequately, which will decrease the need for CVC use. Many previous studies suggested that the benefit of an autogenous fistula is lost when a patient is started on a CVC and then has an AVF created.[17]

There is a wide variation among worldwide countries regarding the types of accesses being used for ESRD patients on HD. In Europe, 66% of new patients start their HD through AVF compared to 15% in the USA, whereas catheters are more widely used in USA among newly diagnosed ESRD patients, with a percentage of 60% versus 31% in Europe.[18]

Our study shown that in Libya the practice pattern is similar, where we recorded that, 82.1% of the patients have AVF, while CVC is the second most common access type practiced in Libya; where (7.8%) of the patients have permanent catheters and (5.9%) have temporary catheters, compared to a previous study done in 2012 on Libyan hemodialysis population (n=1573), showed a higher percentage of using AVF (91.9%).[19]

Arterio-venous fistula is the practiced pattern of vascular access for hemodialysis worldwide especially in the developed countries, with different percentage; Germany (84%), France (77%), Italy (90%), Egypt (67.3%) and In the USA (63.4%) in 2014.[16],[19],[20] whereas the proportion of CVC is low in developed countries such as France (6%), Germany (4%) Spain (7%), and in the USA (15%).[14],[21] This change in pattern of practice, is likely due to psycho-social acceptance of the disease itself and financial reasons to have AVF created on own cost, as the number of public facilities for such surgery are not feasible at current time, other reasons include failure of previous AVF or delay in having surgery.

AVG is the least access type used all over, as noticed in our study that only small percentage (4.1%) of patients have AVG as their access for hemodialysis, this is applied also to the USA data, as the use of AVG for hemodialysis has dropped dramatically from 40% to 18% only.[1]

Access complications contribute to ineffective dialysis and interruptions in treatment, which further contribute to the cost of care. Significant problems with AFVs include non-maturation and early thrombosis. Some studies have shown an early failure rate as high as 46%.[8] If no suitable vessels are available, or when all vessels in the arm are exhausted, a prosthetic AVG can be used.[9]

The risk of infection is high for an AVG compared to an autogenous AVF, but primary patency may be higher.[10]

It is well known that the autogenously AVF is superior to the other modalities in terms of patency rates and infection risk. This is reflected in local and international guidelines where it is recommended as the primary option for all patients on hemodialysis.[9],[10] The Fistula First Breakthrough Initiative and the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines in 2006 set in motion a drive to create more AFVs and limit the use of CVCs.[7]

The most common problem with AVG is stenosis due to an abnormal turbulent flow pattern, which causes focal shear stress in the native blood vessel and neo-intimal hyperplasia, which ultimately leads to narrowing and thrombosis of the graft.[22]

Most of the patients come late to hemodialysis facilities, and start dialysis as an emergency therapy; this leads to use CVC as access for hemodialysis, which is associated with very serious complications, such thrombosis, infection and central venous stenosis.

Vascular access thrombosis and infection are serious complications happen with inappropriate use and care of vascular access. CVCs have a high-risk of infection, which causes permanent damage to the native vessels, further leads to central venous stenosis and occlusion, eventually limiting future access modalities. They also cause less hemodynamic change and no increase in blood flow to the heart, which may be important in patients with congestive cardiac failure.[23] But still they do have some benefits as they could be used as soon as they are placed when urgent dialysis is required.

In this study, the documented complication of vascular access may be underestimated as we relied upon the accuracy of the patient records; that showed, near a quarter of patients have vascular access thrombosis and is considered the most common cause of vascular access dysfunction and failure. Infection of vascular access is the second most common complication recorded in our study, which is associated with increased morbidity and mortality. Central venous stenosis or occlusion was recorded in only (12.4%) patients as evidence of central venous obstruction and stenosis may even be more underestimated since patients are not routinely screened for such complication and only clinically apparent central venous obstruction is recorded. The long-term use of CVCs leads to central venous stenosis, which further compromise future access options.[24]

The late creation of an AVF is another additional problem, as some patients and even dialysis staff do not wait for the fistula to mature causing even more troubling complications; such as hematomas, thrombosis that lead to fistula poor function or even failure. A planned pre-emptive fistula creation should ideally be fashioned three to six months before the first hemodialysis session to allow for maturation and re-intervention if necessary.[25]

A dedicated vascular access coordinator with a pre-operative ultrasound protocol was shown to be the most important factor in improving hemodialysis access outcomes, moreover, joint clinics with surgeon is the ideal practice to be adopted to overcome the difficulties in access availability for hemodialysis.

Another strategy proven to improve outcomes includes pre-operative ultrasound to evaluate the size and quality of the veins to be used. Early referral to the vascular access surgeon, as well as a structured pre-dialysis care program allows the patient to be adequately prepared with counseling and training. Regular multidisciplinary meetings are useful to refer new patients, discuss patients with early concerns about access complications and deal with problematic vascular access.


  Conclusion Top


We concluded that although a high percentage of patients have arterio-venous fistula, still pre-emptive arterio-venous fistula counts very low percentage, and starting of chronic hemodialysis by using acute dialysis catheter is the main practice; most likely due to patients' unawareness of benefit and unfeasibility of arterio-venous creation. Very serious complications are still happening adding burden on patients' health due to inefficiency of hemodialysis and burden on country's health economics with additive costs of hospitalization for treatment. We recommend the establishment of joined pre-dialysis clinic with surgeons and psychologists in each dialysis center or at least in referral centers to provide better care and education of patients for early fistula creation and to plan the management.

The use of central venous catheter, even for a short period, should be discouraged. This practice relies on the timeous identification and referral of patients with chronic kidney disease.

Acknowledgments

The authors gratefully acknowledge the support of the Authority of Azzawiyah Kidney Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
United States Renal Data System. 2016 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2016.  Back to cited text no. 1
    
2.
United States Renal Data System. 2010 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2010.  Back to cited text no. 2
    
3.
Rao GM. Diabetes mellitus in Libya: A retrospective study. Indian J Med Sci 1992;46:174-81.1.  Back to cited text no. 3
    
4.
Roaeid RB, Kablan AA. Diabetes mortality and causes of death in Benghazi: A 5-year retrospective analysis of death certificates. East Mediterr Health J 2010;16:65-9.  Back to cited text no. 4
    
5.
WHO: Eastern Mediterranean Regional Health Systems Observatory- Health Systems Profile- Libya. WHO; 2007. Available from: http://www.emro.who.int. [Last accessed on 2020 Dec 11].  Back to cited text no. 5
    
6.
Salam AA, Alshekteria AA, Abd Alhadi H, Ahmed M, Mohammed A. Patient satisfaction with quality of primary health care in Benghazi, Libya. Libyan J Med. 2010;5. doi: 10.3402/ljm.v5i0.4873. PMID: 21483587; PMCID: PMC3071165, doi:10.3402/ljm.v5i0.4873.  Back to cited text no. 6
    
7.
Alashek WA, McIntyre CW, Taal MW. Provision and quality of dialysis services in Libya. Hemodial Int 2011;15:444-52.  Back to cited text no. 7
    
8.
Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48 Suppl 1:S176-247.  Back to cited text no. 8
    
9.
Hirth RA, Turenne MN, Woods JD, Young EW, Port FK, Pauly MV, et al. Predictors of type of vascular access in hemodialysis patients. JAMA 1996;276:1303-8.  Back to cited text no. 9
    
10.
Ahmed GM, Mansour MO, Elfatih M, Khalid KE, Ahmed Mel I. Outcomes of arteriovenous fistula for hemodialysis in Sudanese patients: Single-center experience. Saudi J Kidney Dis Transpl 2012;23:152-7.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Kolb I, Twagirumugabe T, Uyisabye I, Muhizi J, Braun-Parvez L, Richter S, et al. Emergency vascular access conversion to native arterio veinous fistula: A prospective study of 37 hemodialysis patients in Rwanda. Nephrol Ther 2014;10:457-62.  Back to cited text no. 11
    
12.
Alhassan SU, Adamu B, Abdu A, Aji SA. Outcome and complications of permanent hemodialysis vascular access in Nigerians: A single centre experience. Ann Afr Med 2013;12:127-30.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Ilhan G, Esi E, Bozok S, Yürekli I, Özpak B, Özelçi A, et al. The clinical utility of vascular mapping with Doppler ultrasound prior to arteriovenous fistula construction for hemodialysis access. J Vasc Access 2013;14:83-8.  Back to cited text no. 13
    
14.
Lancashire JF, Steele M, Swinbank A, Du Toit D, Jackson MJ. A 10-year review of a vascular access service for patients receiving hemodialysis: Analysis of procedural modifications and service innovations. J Assoc Vasc Access 2016;21:93-102.  Back to cited text no. 14
    
15.
Yuo TH, Chaer RA, Dillavou ED, Leers SA, Makaroun MS. Patients started on hemodialysis with tunneled dialysis catheter have similar survival after arteriovenous fistula and arteriovenous graft creation. J Vasc Surg 2015;62:1590- 7.e2.  Back to cited text no. 15
    
16.
Pisoni RL, Young EW, Dykstra DM, Greenwood RN, Hecking E, Gillespie B, et al. Vascular access use in Europe and the United States: Results from the DOPPS. Kidney Int 2002;61:305-16.  Back to cited text no. 16
    
17.
Fokou M, Teyang A, Ashuntantang G, Kaze F, Eyenga VC, Chichom Mefire A, et al. Complications of arteriovenous fistula for hemodialysis: An 8-year study. Ann Vasc Surg 2012;26:680-4.  Back to cited text no. 17
    
18.
Alashek WA, McIntyre CW, Taal MW. Vascular access in patients receiving hemodialysis in Libya. J Vasc Access 2012;13:468-74.  Back to cited text no. 18
    
19.
Fissell RB, Fuller DS, Morgenstern H, Gillespie BW, Mendelssohn DC, Rayner HC, et al. Hemodialysis patient preference for type of vascular access: Variation and predictors across countries in the DOPPS. J Vasc Access 2013;14:264-72.  Back to cited text no. 19
    
20.
Ethier J, Mendelssohn DC, Elder SJ, Hasegawa T, Akizawa T, Akiba T, et al. Vascular access use and outcomes: An international perspective from the Dialysis Outcomes and Practice Patterns study. Nephrol Dial Transplant 2008;23:3219-26.  Back to cited text no. 20
    
21.
Pisoni RL, Zepel L, Port FK, Robinson BM. Trends in US vascular access use, patient preferences, and related practices: An update from the US DOPPS practice monitor with international comparisons. Am J Kidney Dis 2015;65:905-15.  Back to cited text no. 21
    
22.
Donati G, Cianciolo G, Mauro R, Rucci P, Scrivo A, Marchetti A, et al. PTFE grafts versus tunneled cuffed catheters for hemodialysis: Which is the second choice when arteriovenous fistula is not feasible? Artif Organs 2015;39:134-41.  Back to cited text no. 22
    
23.
Roca-Tey R. Permanent arteriovenous fistula or catheter dialysis for heart failure patients. J Vasc Access 2016;17 Suppl 1:S23-9.  Back to cited text no. 23
    
24.
Jakimowicz T, Galazka Z, Grochowiecki T, Nazarewski S, Szmidt J. Vascular access for haemodialysis in patients with central vein thrombosis. Eur J Vasc Endovasc Surg 2011;42:842-9.  Back to cited text no. 24
    
25.
National Kidney Foundation. KDOQI 2006 vascular access guidelines. Am J Kidney Dis 2006;48:177-322.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed740    
    Printed8    
    Emailed0    
    PDF Downloaded74    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]