|Year : 2021 | Volume
| Issue : 1 | Page : 141-147
Vascular access in hemodialysis patients – Tanta University Hospital hemodialysis center's experience
Manal S Negm, Rasha Y Hagag, Shimaa H El-attar, Ghada M Alghazaly
Internal Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||13-Sep-2020|
|Date of Decision||16-Oct-2020|
|Date of Acceptance||20-Oct-2020|
|Date of Web Publication||27-Mar-2021|
Ghada M Alghazaly
Assistant Professor of Internal Medicine, Faculty of Medicine, Tanta University, Internal Medicine, Department Faculty of Medicine Tanta University Algesh Street, Tanta
Source of Support: None, Conflict of Interest: None
A well-functioning vascular access is essential to provide efficient dialysis therapy. Morbidity related to vascular access is the leading cause of hospitalization in hemodialysis (HD) patients.
To analyze the vascular access in maintenance HD patients and to assess its associated complications.
Patients and methods
A total of 101 patients on regular HD were included, and data were collected through a preformed questionnaire focusing on vascular access.
Of the 101 patients studied, the vascular access at initiation of HD was temporary catheter in 95% and arteriovenous fistula (AVF) in 5% of the patients. Current vascular access was native AVF in 94%, temporary catheters in 1%, and permanent tunneled cuffed catheter in 5% of the patients. No arteriovenous graft was created. A tunneled catheter was inserted in the internal jugular vein in 99% of cases. A native AVF was created in 99% of the patients as the first permanent access. It was radioscephalic in 35%. The primary failure rate was 14%. The commonest complication with AVF was thrombosis (21%).
Temporary dialysis catheters were the most common initial vascular access. Native AVF was the most common vascular access. Thrombosis was the most common complication.
Keywords: hemodialysis, shunt, Tanta, thrombosis, vascular access
|How to cite this article:|
Negm MS, Hagag RY, El-attar SH, Alghazaly GM. Vascular access in hemodialysis patients – Tanta University Hospital hemodialysis center's experience. Menoufia Med J 2021;34:141-7
|How to cite this URL:|
Negm MS, Hagag RY, El-attar SH, Alghazaly GM. Vascular access in hemodialysis patients – Tanta University Hospital hemodialysis center's experience. Menoufia Med J [serial online] 2021 [cited 2021 Jun 21];34:141-7. Available from: http://www.mmj.eg.net/text.asp?2021/34/1/141/312050
| Introduction|| |
A well-functioning vascular access is essential to provide efficient dialysis therapy . There are three main types of access: native arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (temporary or permanent) . Epidemiological data on vascular access usage in patients with end-stage kidney disease (ESKD) across countries have shown a considerable variation .
National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI), and other international guidelines encourage the creation of autogenous AVFs for hemodialysis (HD) vascular access over prosthetic AVG and discourage the use of HD central venous catheters (CVCs) . However, determining the optimal type of vascular access in any individual patient can be more complex, necessitating consideration of multiple factors, including patient-related factors, access circuit characteristics, and surgical considerations .
Complications of vascular access are the main causes of morbidity in chronic HD patients and contribute to a high percentage of hospitalizations, resulting in high health care costs . Therefore, the analysis of vascular access is essential for its adequacy in relation to recommended guidelines and to reduce morbidity and improve quality of life of dialysis patients .
This study aimed to analyze the vascular access in maintenance HD patients and to assess its associated complications.
| Patients and methods|| |
This retrospective study was carried out in the nephrology and dialysis units of our Internal Medicine Department in the period between November 2019 and May 2020. All patients who were on HD for ESKD in our dialysis units during this period were included in the study.
A total of 101 patients with ESKD on regular HD were enrolled. They were receiving bicarbonate base dialysis using a low-flux dialyzer, with an average blood flow of 300–350 ml/min, three times/week with target 4-h duration for each dialysis session.
Patients were interviewed during dialysis session, and data were collected in a preformed questionnaire. All patients underwent detailed history taking, and data were collected on age, sex, cardiovascular or peripheral vascular diseases, causes of end-stage kidney disease, frequency and duration of HD, vascular access at the time of initiation of dialysis, current and previous access and access complication, and the dry weight measurement. Patients were further evaluated using thorough clinical examinations and reviewed by patients' files. All the data collected were tabulated using MS Excel and were statistically analyzed.
The study was approved by the Ethics Committee of the Faculty of Medicine of Tanta University. Informed consent was obtained from all the patients after full explanation of the study.
Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), version 26, for Windows (2019; SPSS Inc., Chicago, Illinois, USA). For quantitative data, we use the Shapiro–Wilk test for normality. The mean ± SD was used for data that followed normal distribution. The median and range were used for data that did not follow normal distribution, Mann–Whitney test was used to compare between two unpaired groups. For qualitative data, the variables were summarized as frequencies (count and percentage). Pearson's χ2 test was used for independence, and Fisher's exact test or Fisher–Freeman–Halton exact test was used to examine association between two categorical variables as appropriate. Backward, stepwise, binomial logistic regression was performed to assess the effect of potential risk factors on probability of AVF thrombosis. A P value less than or equal to 0.05 was adopted to interpret significance of statistical tests .
| Results|| |
Of 101 patients studied, there were 56 (55.4%) males and 45 (44.6%) females. Their mean age was 53 ± 14 years (range, 22–85 years). Patients were on HD for a median duration of 5.0 years (range, <1–20.0 years). The cause of end-stage kidney disease was hypertension in 34.7% (n = 35) of the patients, diabetes in 9.9% (n = 10), both diabetes and hypertension in 13.9% (n = 14), chronic glomerulonephritis in 5% (n = 5), obstructive nephropathy in 11.9% (n = 12), polycystic kidney disease in 5.9% (n = 6), drug induced in 7.9% (n = 8), and miscellaneous causes in 10.9% (n = 11) of the patients. All the patients received three HD sessions per week. Comorbid conditions included cardiovascular disease in 16.8% of the patients. The baseline demographic and other characteristics of patients are presented in [Table 1].
The vascular access at initiation of HD was temporary catheter (TC) in 95% (n = 96) of the patient and AVF in 5% (n = 5) of the patients and none through AVG or permanent catheter. The current vascular access was native AVF in 94% (n = 95), TCs in 1% (n = 1), and permanent catheter in 5% (n = 5) of the patients. No AVG was created in our patients [Table 2].
|Table 2: Number of temporary catheter and arteriovenous fistula created in the patients|
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A temporary venous catheter was placed for initiation of HD in 96 (95%) patients. A total of 296 catheters were inserted. It was inserted in the internal jugular vein in 99% (n = 95) of cases and in the femoral and subclavian veins in 31.3% (n = 30) and 5.2% (n = 5) of cases, respectively. A total of 71 patients had at least two catheters inserted. The median number of TCs used per patient was 2 (range, 1–11 catheters) and the median duration of their use was 2 months (range, 1–8 months). Complications of TC occurred in 63 (65.6%) patients. Catheter-related sepsis (CRS) occurred in 56 (58.3%), thrombosis in 10 (10.5%), stenosis in two (2.1%) and dislocation in two (2.1%) patients [Table 3].
A native AVF was created in 100 (99%) patients as the first permanent access. It was radiocephalic in 35% and branchiocephalic in 65% of the patients. A total of 135 AVFs were created (70 patients had one AVF, 25 patients had two AVF, and five patients had three or more AVFs because of recurrent complications) [Table 2].
The primary failure rate was 14%, and the median time to first cannulation was 40 (range, 30–90 days). The commonest complication encountered with AVF was thrombosis (21%), aneurysm (2%), stenosis (2%), and rupture (1%) of the patients [Table 4].
The median survival of the primary AVF was 36 months (range, 1–192 months). Creation of a second native AVF was necessary in 35 patients and consisted of creation of a new AVF in the ipsilateral limb in 17 (48.6%) patients with proximality in the same limb in relation to primary AVF in 12 (34.3%) patients, and creation of a new AVF in the contralateral upper limb in 18 (51.4%) patients [Table 4].
A tunneled cuffed catheter was inserted in five (5%) patients. Each catheter was placed in the subclavian vein. A median time of use was 7 months (range, 5–40 month). CRS occurred in two (40%) patients.
Univariate analysis was done to identify potential risk factors of AVF thrombosis and showed no significant relationship between thrombosis and the cause of renal disease, including diabetes (P = 0.191); no significant relationship between thrombosis and the period before first cannulation of AVF (P = 0.592); no significant relationship between thrombosis and the associated cardiovascular disease (P = 0.514); and no significant relationship between thrombosis and the prior TC insertion. The number of TCs used was related to an increased risk of thrombosis (P = 0.001), and this risk increased by the catheter duration (P = 0.008) [Table 5].
Backward, stepwise, logistic regression analysis was done to evaluate the potential risk factors that may affect the occurrence of AVF thrombosis, including causes of ESKD, number of TCs used per patient, and the duration of TC use. The choice of risk factors encountered in the regression model was based on clinical relevance and the P value in univariate analysis (variables were P < 0.2 were considered, according to Bursac et al. ). The logistic regression analysis showed that both number of TCs used per patient and the duration of TC use affected the model when either variable was removed, though the P value from Wald test for duration of catheter was above 0.05. If the number of used TCs increased by one, when the duration was adjusted, the probability of AVF thrombosis increased by 1.3 times (P = 0.05). When the number of catheters was adjusted for, prolonged catheter duration by 1 month was associated with increased likelihood of AVF thrombosis by 1.3 times [Table 6].
|Table 6: Backward stepwise logistic regression analysis for factors contributing to thrombosis (n=100)|
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| Discussion|| |
Our patients were on HD for a median duration of 5.0 years, being comparable to Medkouri et al. , who reported that mean duration of HD in their patients was 98.4 months. However, in the study by Bilhah et al. , the mean duration of HD was 1.7 ± 1.3 years.
Overall, 100% of our patients were on thrice-weekly dialysis correlated with Perez-Garcia et al. who found 97% on thrice-weekly dialysis. However, Kulkarni et al. found 77% on thrice-weekly and 23% on twice-weekly dialysis.
Regarding the cause of ESKD, we reported that hypertension was the most common cause in 34.7% followed by diabetes in 9.9% and then both hypertension and diabetes in 13.9%. Similarly, in the study by Centofanti et al. , the cause was hypertension in 40.5%. However, in the study by Kim et al. , it was diabetic nephropathy in 50.2% and hypertension in 20.3%.
In our study, vascular access at initiation of HD was TC in 95% and AVF in 5% of the patients. Similarly, in Hemachandar , initial access was CVC in 96% and AVF in 4%. However, in Kazakova et al. , 79.5% started with a CVC, 17.2% with fistula, and 3.3% with a graft. The high usage of TCs in our patients may be owing to late presentation and delayed diagnosis and late referrals to a vascular surgeon.
In our study, TCs were inserted in the internal jugular vein in 99% of cases, which was in line with the recommendations of the guidelines for vascular approaches. Comparable to Hemachandar , TCs were inserted in internal jugular vein in 98.27% of cases. However, in Zakaria et al. , the common site for TC was the subclavian vein.
Mean catheter survival was 2 months in our study, in contrast to 35 and 32.3 days reported by Altaee et al. and Centofanti et al. , respectively. It indicates prolonged catheter dependence in our patients because of dialysis initiation through catheters followed by AVF creation, necessitating prolonged catheter use till the maturation of fistula.
In our result, temporary CRS occurred in 58.3%, but in the study by Hemachandar , CRS occurred in 34.48%. CRS was high in our patients probably owing to prolonged dependence on catheters and lack of patient's care of the catheter in spite of the precautions taken in our units to avoid catheter infection.
In the present study, the current vascular access was native AVF in 94% of the patients, TC in 1%, and permanent catheter in 5%. It is comparable to Bilhah et al. , who showed that their current vascular access was native AVF in 90.7% and TC in 4.7%, permanent catheter in 3.7%, and AVG in 0.9% of the patients.
In our study, native AVF was radiocephalic in 35% and brachiocephalic in 65% of patients, but Anoop et al. found that ~34.3% were brachiocephalic and 65.7% radiocephalic. Our results are not in line with KDOQI guidelines to preserve proximal vessels for future use; this may be owing to the delayed referral of the patients to the vascular surgery after puncturing the proximal veins for peripheral cannulas owing to delayed referral of patients to HD.
In our study, the median time to first cannulation of AVF was 40 days. This was similar to Hemachandar (46.65 ± 2.55 days). However, Medkouri et al. found that it was 15 days in their study. Maturation times of 1–4 months must elapse following creation of an autologous fistula, and early cannulation of the fistula carries the risk of complications.
In our study, the primary failure of AVF was 14%. This matched with the results of Magar et al. (14.1%), but the results of Anoop et al. were less than us (12.8%), and our results are lower than that of Kulkarni et al. (33%), where the causes of fistula failure were thrombosis, early cannulation, and weak veins.
In our study, median survival of the primary AVF was 36 months. In the study of Centofanti et al. , the survival was 48.1 months, and 54.8 months in the study of Medkouri et al. . Survival was shortened by many complications, commonly thrombosis in 21% of our patients.
In our study, tunneled cuffed catheter was inserted in the subclavian vein. Similarly, Jemcov and Dimkovic reported that the common localization of it was subclavian vein, but Medkouri et al. reported that it was inserted in the right internal jugular vein. No AVG was created in our patients owing to lack of proper products, high costs, and lack of the experts to do it.
In our study, thrombosis of the AVF was the commonest complication occurred in 21% of patients. In the study of Thabet et al. , thrombosis was found in 17.6%. Our result does not go in harmony with Derakhshanfar et al. and Cavallaro et al. who reported the commonest complication found in their patients was aneurysm in 51 and 50%, respectively.
Our study showed no significant association between AVF thrombosis and diabetes. Similarly, Sedlacek et al. , Korn et al. , and Saifan et al. found no association between AVF thrombosis and diabetes. On the contrary, Bahadi et al. found that diabetes was associated with AVF thrombosis in their patients.
The period before first cannulation did not increase the risk of AVF thrombosis in our group, which is in contrast to the study of Rayner et al. , who found higher risk of thrombosis with cannulation within first 14 days after fistula creation; this may be explained by the long duration we gave it to our patients before first cannulation for maturation of their fistulae.
In our study, the number of TCs used was related to risk of thrombosis, and this risk increased by duration of their use. Medkouri et al. as well showed that number of TCs was related to risk of thrombosis, but risk was not increased by duration of their use.
| Conclusion|| |
- Internal jugular vein catheters were the most common initial vascular access. Only 5% of patients started dialysis with AVF.
- Native AVF was the most common current vascular access with very small number of permanent catheters.
- No AVG was created in our patients.
- Thrombosis was the most common complication of AVF. Risk relates both to the number of previous catheters and their combined duration, suggesting that one way to reduce thrombotic events of AVF may be to avoid catheter use whenever possible.
- Close follow-up of patients with chronic kidney disease and early referral of them to vascular surgery for native AVF creation when they are expected to need HD should be done.
- Reducing the catheter time use is essential to reduce the risks associated with dialysis catheters.
- Regular monitoring of the vascular access especially in people who are at risk for adverse outcomes should be done.
For this, we put a plan to the residents in our unit on how to deal with the patients with CKD and when to refer to vascular surgery.
Our study had some limitations. The retrospective design from a single center emphasizes the need of additional research in that area, especially multicenter research, involving several teams.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]