Division of Nephrology, Dialysis and Transplantation, University Hospital Modena, Modena, Italy
Correspondence and offprint requests to: Decenzio Bonucchi MD, Division of Nephrology, Dialysis and Transplantation, University Hospital, Modena, Via del Pozzo, 71, I-41100 Modena, Italy.
Abstract
Background. To obtain information on the management of vascular access in Italy.
Method. Questionnaire sent to all dialysis centres. The main questions were: (i) who is in charge of establishing vascular access? (ii) How is vascular access monitored? (iii) To what extent is a continuous quality programme implemented? (iv) What proportion of patients are treated using central venous catheters at the start of dialysis? (v) What proportion of patients are treated using central venous catheters as a permanent access? (vi) What is the role of interventional radiology?
Results. The response rate was 45%. All Italian regions were represented. In almost 80% of the dialysis centres vascular access is established by the nephrologist. Fistula function is monitored by most nephrologists using a recirculation test, ultrasound and radiological imaging. An audit (continuous quality programme) is implemented in 20% of the dialysis centres. A high proportion of patients are submitted for dialysis without an internal AV fistula (in one quarter of the centres more than 40% of the patients). Less than 10% of the patients are dialysed using central venous catheters as a permanent access. Interventional radiology for vascular access is used only in few centres.
Comments. Because of the difficulty of coordinating different professionals, most nephrologists manage vascular access by themselves. Fistula function is usually monitored on a routine basis, but a `Continuous Quality Programme' on established standards and audit of outcome and process indicators is not followed in most centres. Late referral is a main obstacle to effective planning of renal care, as indicated by the high frequency of temporary access at the beginning of dialysis. On the whole, vascular access is properly managed by Italian nephrologists, but monitoring performance by audit would be desirable.
Keywords: central venous catheters; interventional radiology; management; quality; vascular access
Introduction
Quality of vascular access determines patients' well-being as well as costs and efficacy of dialysis treatment. Creation of vascular access for dialysis requires interaction between different professionals, e.g. vascular surgeon, radiologist and nephrologist. There are large differences between countries in how this goal is implemented. It was the purpose of the present analysis of a representative sample of Italian dialysis centres to (i) obtain data on how vascular access surgery is managed; (ii) to evaluate what procedures are chosen to establish vascular access; and (iii) to monitor outcome.
Methods
A questionnaire was sent to all Italian dialysis centres 45% of which replied (n=250). The following questions were posed: (i) whether vascular access surgery was managed by a nephrologist or a vascular surgeon? [`management' implies organizing, caring for and creating vascular access; (ii) How graft function was monitored? (iii) Whether an audit was performed, i.e. whether a `Continuous Quality Improvement Programme' has been established? (iv) How frequently venous catheters were used as the first access for patients with end-stage renal disease (ESRD)? (v) How frequently central venous catheters were used as a permanent access; and (vi) which role interventional radiology played in the respective centre? The results are shown in Table 1.
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Vascular access problems must be arranged quickly. Often it is difficult for the nephrologist to arrange collaboration with other specialists, e.g. vascular surgeon, radiologist etc. in a short period of time. Therefore, he is frequently forced to resolve the problem all by himself.
This survey reveals that central catheters at the start of dialysis are very frequently used in dialysis patients with ESRD. This must certainly be interpreted as an index of `late referral'. According to the questionnaire, a quarter of Italian dialysis centres experience the problem of late referral in more than 40% of patients admitted for renal replacement therapy.
In order to reduce the use of central venous catheters it is necessary to reduce late referral. This will help to save the vasculature of uraemic patients and to establish vascular access well in advance of the start of dialysis.
The nephrologist should consider three approaches: (i) educate the general practitioners so that renal patients are referred intime to the nephrologist; (ii) educate the staff to save the vessels of the forearm in the patient with renal disease and (iii) to improve specialist training for physicians responsible for creating vascular access.
The first two objectives provide a direct challenge to the nephrologist involved. With respect to the third objective it is necessary to apply the principles of `Continuous Quality Improvement', i.e. an interactive process describing the standard and controlling the outcomes of medical services with the aim to improve results. In the particular case of creating vascular access, it could involve accreditation of surgeons, audit of short-term outcomes, monitoring of patency and complications, frequency of use of central venous catheters etc. Undoubtedly, the experience of the operator is the chief factor determining long-term outcome of vascular access surgery.
The response to the questionnaire shows that a programme of `Continuous Quality Improvement' is still lacking in 80% of Italian centres. We wish to encourage centres to use and validate indicators of process quality, for instance the prevalence of central venous catheters (transitory at the beginning of treatment or permanent).
The vascular surgeon should be involved in more complex cases, but strategic decisions should remain the domain of the nephrologist, i.e. movement of the site of vascular access to progressively more centripetal locations, selection of the dialysis technique, selection of type of access as a function of the expected technique survival time of the patient. Interventional radiology plays a marginal role at best. The good results that can be obtained with this technique are obtained only if there is a regular programme of surveillance involving the radiologist.
The best solution would be to establish groups of physicians dedicated to the task of vascular access. These should comprise vascular surgeon, interventional radiologist, dialysis nurse and (as a coordinator) nephrologist. These should be established in a hospital with a catchment area of approximately 500 000 inhabitants.
One important problem is not addressed by this survey, i.e. the use of vascular prosthesis. In Italy, the possibility of creating an internal fistula is always the first consideration. The availability of central venous catheters, the spread of CAPD and the prolonged prohibition to use of biological material has strongly limited the use of prosthesis. In contrast, in the USA, the use of PTFE grafts is widespread. In order to avoid a similar error in Europe with respect to the central venous catheters, the following recommendations are appropriate: to maintain the prevalence of central venous catheters at the lowest possible level, to establish an internal fistula in good time and to re-evaluate in frequent intervals the patient with central venous catheters to find out whether an internal fistula has become possible.
There remains one open question: which is better, synthetic prosthesis or central venous catheter? In our opinion one must take into consideration the life expectancy of the patients: in many elderly patients a central venous catheter may be a compromise on humanitarian grounds.
In Italy, from the very beginning, many nephrologists have been in charge of vascular access of their patients and the great majority continues to take care of it. It is now time to measure their performance.
Editor's note
Please see also Invited Comment by Konner (pp. 20942098) and Dialysis and Transplantation News by Ezzahiri et al. (pp. 21102115).
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