O G I D KDIGO Controversies Conference on Dialysis Initiation, - PowerPoint PPT Presentation

Appropriate Dialysis Access - Timing & Preparation for Dialysis Initiation O G I D KDIGO Controversies Conference on Dialysis Initiation, Modality Choice K and Prescription, Madrid, Spain, Jan 2018 Kevan Polkinghorne Monash Medical Centre, Melbourne, Australia

Talk Summary • Dialysis Access Practice Patterns • Dialysis Access Types O G – Advantages/Disadvantages I D – Patency/Complications K • Determining the Timing of Dialysis Access Placement – Individual Patient Factors - Morbidity – Physician Based Factors – “Patient Factors” – Traits/Cultural Factors KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Current Dialysis Access Access Practice O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Current Dialysis Access Access Practice (2012-2015) Incident Patients Prevalent Patients O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Peritoneal Dialysis (2013) O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Dialysis Access Types • Advantage and Disadvantages O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Arteriovenous fistula • Advantages • Disadvantages – Lower risk of Mortality (?) – High rate primary failure O G – Lowest infection risk – Prolonged maturation time I D – Lower risk of hospitalisation – Ischaemic Steal K – Longer patency once established – Not suitable in all patients • Elderly ? – Cheaper especially if no primary • Sign morbidity ? failure – ?Expensive – Adequate Blood Flow once mature KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Arteriovenous graft • Advantages • Disadvantages – No prolonged maturation period – Higher Infection risk compared to O AVF G – Patency comparable to AVF if I D include primary failure – Need for (multiple) interventions K to maintain patency – Lower infection risk compared to CVC – Vascular Steal – ? Good Choice in Elderly – Cost – Reduce line exposure time KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

CVC • Advantages • Disadvantages – No maturation period – Increased Mortality (?) O G – Suitable in Co-morbid Patients – Infection I D – Patient Factors eg Needle Phobia – Dysfunction common K – Central Venous Stenosis – Higher costs – Patient Factors (dressings etc) KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Peritoneal Dialysis • Advantages • Disadvantages – Survival Advantage in first year? – Home based therapy O G – No prolonged maturation period – Infection I D – Home based therapy – Patency/Technique Failure K (Predominantly) – Not suitable for a large number of – QOL ? patients KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Dialysis Access Types • Patency O • Other Complications G I • Mortality D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Vascular Access Patency • Patency definitions vary enormously in the literature O G I D • Need to consider effects of changes in nature K of dialysis population from 1980’s – 1990’s to 2000’s • Majority Non-randomized comparisons KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

O G I Primary Failure Rate 23% (18-28%) D K Al-Jaishi etal , AJKD 2014 KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Overall 1 year Primary Unassisted Patency 64% O G I Mean of 20 months D K Bylsma, et al Eur J Vasc Endovasc Surg 2017 KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

O G I D K Bylsma, et al Eur J Vasc Endovasc Surg 2017 KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Overall 1 year Secondary Patency 79% Mean of 28 months O G I D K Bylsma, et al Eur J Vasc Endovasc Surg 2017 KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Primary Failure Included Primary Failure Excluded O G I D K 2x angioplasties in AVG, more thrombosis Lok, C. E., et al cJASN 2013 KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

CVC Patency • No Large contemporary studies of CVC complications. O • CVC Patency estimates range between 34 to 78% over 1 year G I D » NDT 1992, NDT 2004, J Vasc Radiol 2013 K • Up to 87% of catheters develop dysfunction during the course of their use and 30% develop dysfunction monthly » AJKD 1996, In J Nephrol 2011 • <10% of CVC survive 1 year without need for intervention KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

CVC and Central Vein Stenosis • Central Vein Stenosis can be as high as 40% in haemodialysis population O G I D K • Risk factors include previous CVC placement, number of CVC’s and duration of CVC placement. • Again not well studied KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Other Dialysis Access Complications O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Vascular Access Complications: DOPPS O G I D K Ravani P cJASN 2017. KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Vascular Access Complication: DOPPS O G I D K Ravani P cJASN 2017. KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Other Dialysis Access Complications O G I D K Also No Differences Age<65 versus Age≥65 years Ravani, P., et al JASN 2013 KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Dialysis Access and Mortality O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Dialysis Access and Mortality O G I D K Also No Differences Age<65 versus Age≥65 years Selection Bias, Residual Confounding Ravani, P., et al JASN 2013 KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Determining the Timing of Dialysis Access Placement O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Determining the Timing of Dialysis Access Placement • What do the guidelines say? O G I D K KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

Timing of PD Catheter Placement • ISPD Guidelines 2010 – We suggest that, whenever possible, catheter insertion should be performed at least 2 weeks before starting PD. • UK Renal Association 2017 O – We recommend that, where possible, timing of PD catheter insertion should be planned to G accommodate patient convenience, commencement of training between 10 days and 6 I D weeks and before RRT is essential to enable correction of early catheter-related problems K without the need for temporary haemodialysis. • KDOQI 2006 – A peritoneal dialysis (PD) catheter ideally should be placed at least 2 weeks before the anticipated start of dialysis treatments. – A backup HD access does not need to be placed in most patients. A PD catheter may be used as a bridge for a fistula in “appropriate” patients. KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain