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Dialysis Community Collaboration: A Multidisciplinary Approach to Patient Care

Discussing the need for collaboration and communication across nephrology, vascular surgery, and interventional radiology to benefit patient care.

By David B. Kingsmore, MD, FRCS, and Peter C. Thomson, MD, FRCP

There are currently 63,162 patients requiring renal replacement therapy (RRT) in the United Kingdom, of whom 22,261 (41%) are treated with hemodialysis.1 These figures are representative of worldwide data. For example, according to a recent report from the United States Renal Data System, there were 124,675 new patients registered with end-stage renal disease (ESRD) on hemodialysis during 2016, bringing the total to 726,331 patients with ESRD on hemodialysis; this carried an expenditure of $114 billion for 1 year.2 These figures are projected to rise as they have for the past 15 years. The patient population currently being treated has not only increased in number but has also increased in medical comorbidity. Transplantation has been very successful, but this has altered the dialysis population with an increasing proportion who are elderly, comorbid, and frail, alongside those who are actively waiting for a transplant (average time on the waiting list is 3 years) and those who are returning to regular dialysis following a failed transplant (average lifespan of a transplant is 10 years).

A key variable in the cost of hemodialysis is its method of delivery—vascular access. From a superficial viewpoint, provision of good vascular access should be straightforward; when hemodialysis is required, an arteriovenous fistula (AVF) should be created because it has a lower cost and requires fewer maintenance interventions than the alternatives such as tunneled central venous catheters (TCVCs) or arteriovenous grafts (AVGs). However, despite significant pressure from organizations, health care providers, professional societies, and guidelines, there remains wide variation in the proportion of patients who start and are maintained on hemodialysis through arteriovenous access. This may be because obtaining vascular access is not a simple process, as each step of the pathway has nuances, influences, preconceptions, and subtle drivers. Simply focusing on one component separate from the overall process is unlikely to lead to significant changes because competing interests and unforeseen opposing needs may minimize and negate improvements. This can be seen in the stalling of the Fistula First Breakthrough Initiative, which led to a large increase in the number of AVFs being created, but the rates of successful AVFs for regular hemodialysis remain largely unchanged.

Vascular access is a key issue in hemodialysis, as it is the main modifiable factor in determining morbidity, mortality, and costs to patients and the service. The three main methods by which vascular access is achieved have been thoroughly studied in isolation, but rarely as part of a comprehensive overall access strategy. For instance, (1) an AVF may have significant delays and failures, necessitating catheters and leading to catheterrelated morbidity; (2) a TCVC may avoid unnecessary and futile surgery but carries a reasonable burden of short- and long-term morbidity; and (3) a prosthetic AVG, despite having more effective utilization, may require an enhanced surveillance program to optimize outcomes. Therefore, patients may endure myriad imaging techniques and procedures with variable rates of success.3 Considering these factors, conventional wisdom until the last few years had been to pursue an AVF in all patients with an estimated glomerular filtration rate (eGFR) of 15 mL/min/1.73 m2 before considering an AVG. More recent data have enabled this approach to be more thoroughly scrutinized.4,5

Preemptively creating a vascular access is futile in many ways: 8% of patients will die in the first year and a similar number will undergo renal transplantation, 5% will convert to peritoneal dialysis, 30% will remain in predialysis, and there is a significant proportion of patients in whom AVF creation is thwarted by primary failure to achieve a functional AVF. However, simply waiting until hemodialysis is established before creating an AVF defaults to catheter use, which can be prolonged and carry higher bacteremia rates, involve replacement procedures for poor central venous catheter patency, and confers poorer longer-term outcomes. There is an increasing understanding that early cannulation grafts may have a larger role in providing reliable vascular access for patients in whom the alternatives have greater costs, both personally to the patient and to the wider expenses involved in providing RRT.5 Furthermore, as the strategic landscape behind a vascular access provision is changing, there are other factors increasingly blurring the traditional separation of surgery, radiology, and nephrology, with interventional nephrologists performing surgery and the development of endovascular techniques that allow radiologists to perform AVF creation.

THE PATIENT JOURNEY

The transition of patients from chronic kidney disease (CKD) to RRT begins with their identification and referral to nephrology services. For many patients, their CKD will have been treated, supported, and tracked through outpatient nephrology clinics for a reasonable period of time, such that when RRT is likely required in the long term, they may receive timely education on their RRT options, determine whether transplantation can be pursued, and if a period of hemodialysis is likely, the role of vascular access in facilitating the effective delivery of hemodialysis can also be explored. Some patients, however, may only be identified at the point of advanced CKD, whereby a considerable amount of clinical activity may be concentrated into a short period of time and may impact the vascular access options available for hemodialysis in the immediate term.

The progression of patients to hemodialysis is highly variable, which makes education and decision-making about the various interventions and their wide range of success and outcomes difficult. In addition, these decisions, which are difficult even for those intrinsically involved in vascular access, are often being made by sick patients who may have limited understanding of the major imminent changes, deep concerns about their immediate future, and uncertainty about their longer-term health. Helping patients with these decisions are low-clearance clinic specialist nurses, nephrologists, and—only after many clinical decisions—surgeons.

Many parts of nephrology seem opaque to those outside the field. It is not often recognized that the bulk of a nephrologist’s workload relates to the prevention and avoidance of ESRD, with hemodialysis often being a smaller part. To nonnephrologists, measures of renal function such as eGFR are often used to gauge the progression of renal failure, but the timing of hemodialysis initiation may be influenced by many more factors, including a patient’s capacity to tolerate the symptoms of uremia, as well as societal or organizational factors. When ESRD progresses toward the need for RRT, the patient pathway is unpredictable. International comparisons show not only wide variation in the eGFR at which RRT is provided between countries but also in the modality of how it is provided. For example, an AVF is the modality of use for the initiation of hemodialysis in only 20% in the United States, compared with up to 80% in some European countries.2 Population-derived scoring systems may help predict the need for RRT, but simply applying these to an individual patient is unlikely to make a significant impact on the overall efficacy of a vascular access provision. This variation in practice remains despite scoring systems, meetings, trials, evidence, and guidelines that all portray vascular access as a simple process. The surgical options are highly varied with technical considerations on the location and methodology of anastomosis and anesthetic techniques to facilitate it, balanced against the spectrum of advantages and disadvantages for each surgical procedure for both the short- and long-term goals of the individual patient. For example, the decision to pursue a wrist AVF rather than an elbow AVF may balance the imminent lower likelihood of success against the better longer-term patency that patients may require in the future.

APPROACHES IN DIALYSIS CARE

The Current Approach

Until recently, the basis to improve provision of vascular access has been to break down the overall aims into its component parts and fix each in isolation—a reductionist approach. This approach is best exemplified by the use of a randomized controlled trial in which one discrete intervention is isolated and improved. Although trials are an essential part of improving contemporary practice, this approach is not well suited for situations that involve many varying participants with complex interactions and interdependency that evolve over time. It is understandable that overall progress toward a unified approach and improved outcomes for vascular access seems as far away as ever with large differences between units, centers, regions, and countries; it cannot simply be that the referral patterns differ.

A Multidisciplinary Approach

A novel approach toward improving health care has been proposed based on complex-systems theory. A complex-systems approach differs from a reductionist approach in that it is dynamic rather than fixed; has many factors necessary to achieve realistic improvements; recognizes that individuals have erratic and varying progression pathways; and is able to be adaptive, utilize opportunities, and minimize unforeseen events. Vascular access is a typical complex system because it involves multiple disciplines, including nursing, surgery, nephrology, and interventional radiology (IR), each competing for ownership of the required resources (increasing surgical input and costs may reduce nephrology bed use while reducing catheter use). It also relies on interdependency (nephrology recognizes and prescribes a treatment that is provided through surgical success), which is ongoing and requires each service to be dependent on another (losses of AV access through poor cannulation or IR intervention to maintain patency). It acknowledges that decisions often have longer-term unforeseen effects (eg, central vein stenosis that presents years later to plague efforts at achieving AV access) that are often self-organized rather than centralized. Furthermore, the patient’s progression to requiring RRT is not easily predictable. Complex decisions about the multitude of options for vascular access are influenced and informed as much from intrinsic philosophy as robust evidence, and complex health needs often supervene planned interventions.

It is vital that an approach is taken that utilizes these separate disciplines to optimize care and focus efforts on the central key person—the patient. It is only through considering the interaction between all of the involved medical specialties, nursing teams, and the patient that significant progress will be made.

This multidisciplinary approach demands clear lines of communication between all specialties and the ability to reference all relevant elements of the patient’s access history and ongoing RRT strategy. Issues must be dealt with promptly and their workup has to fit around regular dialysis schedules, as well as intercurrent illnesses and other health problems. As such, a multidisciplinary approach requires speed, efficiency, flexibility, reliability, and reproducibility.

REAL-WORLD PROGRESS

A recent national appraisal of vascular access services in Scotland highlighted the importance of clearly structured pathways for creating and maintaining access in delivering safe, effective, patient-centered care.6 The initial identification of patients predominately occurs within nephrology services. Clarification of each individual’s RRT goals, relating these to their circumstances, and initiating education and dialogue with patients and their families are required to determine their optimal vascular access solution. Thereafter, imaging specialists are often involved in the practical aspects of catheter placement or assessing the vasculature for placement of AVGs or AVFs by surgical or interventional specialists. Once established, all functioning accesses must be routinely assessed for the development of complications. This is often achieved through educating and involving patients in assessing their own access, regular appraisal of the access during dialysis treatments by nursing staff within the dialysis center, and proactive and/or reactive assessment of access problems by vascular access specialist nurses who may seek onward referral for consideration of intervention for problematic accesses by interventional radiologists or surgical specialists.

Services that established structured patient pathways found that they facilitated the successful configuration of the various health care professionals involved in the patient’s journey. This, in turn, was associated with the most successful outcomes and reported patient experiences.6

CONCLUSION

Fundamentally, improvements in the provision of efficient vascular access care in an economically challenged climate requires a shared vision, simple patient-centered principles, and flexible local care environments.

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  1. Evans K, Pyart R, Steenkamp R, et al. UK Renal Registry 20th annual report: introduction. Nephron. 2018;139(suppl 1):1-12.
  2. Saran R, Robinson B, Abbott KC, et al. US renal data system 2018 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2019;73(suppl 1):S1-S772.
  3. Woo K, Lok CE. New insights into dialysis vascular access: what is the optimal vascular access type and timing of access creation in CKD and dialysis patients? Clin J Am Soc Nephrol. 2016;11:1487-1494.
  4. James MT, Manns BJ, Hemmelgarn BR, Ravani P. What's next after Fistula First: is an arteriovenous graft or central venous catheter preferable when an arteriovenous fistula is not possible? Semin Dial. 2009;22:539-544.
  5. Murray E, Eid M, Traynor JP, et al. The first 365 days on haemodialysis: variation in the haemodialysis access journey and its associated burden. Nephrol Dial Transplant. 2018;33:1244-1250.
  6. Oliver SW, Campbell J, Kingsmore DB, et al. Scottish haemodialysis vascular access appraisal report: relating variation in outcomes to variation in processes: Scottish Renal Registry. https://www.srr.scot.nhs.uk/Projects/PDF/2015/ Scottish-Renal-Registry-vascular-paper-2015.pdf. Accessed March 25, 2019.
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Endovascular Today June 2019 Supplement

Endovascular Today June 2019 Supplement
Raising the Standards for Dialysis Access Care

 

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David B. Kingsmore, MD, FRCS
Consultant Renal and Vascular Surgeon
Queen Elizabeth University Hospital
Glasgow, United Kingdom

Disclosures: Speaking fees and investigator-led small research grant from Proteon Therapeutics and Gore & Associates.
 

Peter C. Thomson, MD, FRCP
Consultant Nephrologist
Queen Elizabeth University Hospital
Glasgow, United Kingdom

Disclosures: Speaking fees and investigator-led small research grant from Proteon Therapeutics and Gore & Associates.