Catheters = Thrombosis SPAIN: Praga, M et al. Nephron Clin Practice, - - PowerPoint PPT Presentation

4/15/2016 1

Debate: We Are Not Using Early Access Grafts Enough and it is Costing us in Catheter-Related Days: PRO

Charmaine Lok, MD, MSc, FRCPC

Professor of Medicine, University of Toronto Medical Director of Hemodialysis, University Health Network

Friday April 15, 2016 UCSF Vascular Symposium 2016 San Francisco

Objectives:

To try to convince you that:

• 1. Hemodialysis catheters (CVCs) can be costly - patient health
• utcomes and healthcare resources
• 1. Early cannulation grafts can spare catheter days
• 2. Early cannulation grafts have similar outcomes as “standard

grafts”

3.

Grafts have similar outcomes as fistulas

4.

Early cannulation grafts can be cost effective

• 1. HD catheters can be costly: Patient

Poor flows Inadequate Dialysis Thrombosis Interventions Infection Bleeding risk Fibrin Sheath Central Stenosis Inflammation Malnourishment Catheter Use

DEATH

Worldwide…

Incident or Prevalent patients…

Regardless of AGE, SEX, DIABETES

status or many other factors:

Catheters = inferior survival

SPAIN: Praga, M et al. Nephron Clin Practice, 2013 CANADA: Moist, L. et. al, CJASN, 2008 AUSTRALIA/NEW ZEALAND: Polkinghorne K. et al, JASN, 2004ra Catheter SCOTLAND/UK: Bray, B. et al. QJM, 2012

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Reduce Patient Mortality: Convert to AV-Access

in First Y ear of HD

Change catheter to AV access Adjusted HR for mortality

(95% CI)

Catheter to AV fistula 0.64 (0.47-0.87) Catheter to AV graft 0.71 (0.55-0.92)

5

• Bradbury. AJKD, 2009

DOPPS (1996-2004)

Catheters Last

What about…

YES THEY SHOULD BE IF WE CAN!

Little or no planning

Recall: “Urgent Starts” to dialysis

20-40%

Inadequate time for:

• Referral to surgeon
• Pre-creation corrective

interventions, if required

• Post-creation facilitative

interventions, if required

• Fistula maturation to

use when needed

Other situations exist where eAVG may be useful

• 2. Early cannulation grafts (eAVG) can spare

catheter days

• Concept first introduced in 1997 “Perma-Seal”
• Multi-laminated structure
• Allows cannulation < 72 hours
• Examples: Vectra graft, Flixene graft, Acuseal graft, Avflo graft, Rapidax graft

<72 hrs is <3 days… how urgent is urgent?

For real emergency dialysis - a temporary CVC = in/out once only!

4/15/2016 3 eAVG can spare catheter days

<72 hrs is <3 days… how urgent is urgent?

For real emergency dialysis - a temporary CVC = in/out once only!

Sparing a lot of catheter days

Report USRDS 2015: 103,337 incident HD patients (2013) 80.2% start dialysis with a catheter (N=82,876) At 90 days after HD start, 68.3% still using catheter (N=56,604) 5,094,404 catheter days if 40% were “urgent start”; N=33,150 (2,037,755 CVC days at 90 days if

68.3% still using CVC)

if used eAVG and CVC use * 1 33,150 catheter days

(spare 2,004,605 catheter days by 90 days)

if used eAVG and CVC use *3 99,451 catheter days

(spare 1,938,304 catheter days)

if 20% were “urgent start”: N=16,575 (1,018,865 catheter days)

(spare 969,140-1,002,290 catheter days)

Spare more if used eAVG in non-urgent start situations e.g. elderly

patients with limited life expectancy, high risk patients for fistula failure

Real Life at UHN

43 eAVG 37 Urgent Start 30 Not Yet On Dialysis 27 started using eAVG 3 started With CVC 7 Already on Dialysis 6 Non-urgent

90% without

a CVC!

• 3. eAVG have similar outcomes to standard AVG

Primary and secondary patency at 12 months

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• 4. Grafts have similar outcomes to fistulas
• Retrospective

review (3 years)

• 494 patients, 655

accesses

• 390 AVF, 265 AVG
• AVG fared worse in

assisted primary patency BUT superior secondary patency as compared to AVF

Allemang et al. American Journal of Surgery 2014 Lee, T. et al. J Am Soc Nephrol 18:1936; 2007 Snyder, D.. et al. Am J Surgery; 196:641; 2008

Lok, C.E. and Moist, L. et. al, CJASN, 8: 810; 2013

Grafts have similar outcomes to fistulas

Similar sepsis rate compared with a fistula and lower

infection rates compared with a catheter

0.5 1 1.5 2 2.5 AVF AVG CVC Series1 A

USRDS 2012

1 2 3 4 5 6 7 8 AVF AVG CVC Vascular Access Type % Incident Prevalent

• 5. Early cannulation grafts can be cost effective

US study; Desai, S. et al; J Am Coll Surg; 2015 (abstract)

ESRD pts followed * 6mos (tracked infection, re-intervention, hospitalization) Cost per pt-yr (actual costs projected to 1 yr, using propensity score matching)

• 5. Early cannulation grafts can be cost effective

UK study; Aitken E. et al; J Vasc Access; 2016

• Prospective: CVC pts followed * 6mos (v. mapping, CVC wait times,/delays,

complications etc tracked; eAVG acceptance surveys baseline + 6 mos)

• Data used to model “standard practices” for VA types
• Budget impact model created (hosp perspective)

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Summary & Conclusion:

Hemodialysis catheters (CVCs) can be costly - patient

health outcomes and healthcare resources

• we use them too much which means we are not using eAVG

Early cannulation grafts (eAVG) can spare catheter days eAVG have similar outcomes as “standard grafts” Grafts have similar outcomes as fistulas eAVG grafts can be cost effective

Conclusion: YES, we are not using eAVG enough (despite good reason to use them) and it is costing us in catheter days!

Thank You!

DOC LOK ROCKS! DOC HARLAND PRETTY GREAT TOO!

Questions?