Nephrology Dialysis Transplantation 28 (Supplement 1): i19–i21, 2013 doi:10.1093/ndt/gft150
VASCULAR ACCESS SO061
BARRIERS TO IMPLEMENTING A FISTULA-FIRST POLICY IN EUROPE
S.N. van der Veer1, L. Labriola5, R. Fluck3, K.J. Jager1, L. Coentrão2, W. Kleophas4, P. Ravani6 and W. van Biesen7 1 AMC Amsterdam The Netherlands, 2Porto University Porto Portugal, 3Royal Derby Hosp. Derby United Kingdom, 4Gemeinschaftspraxis Karlstr. Düsseldorf Germany, 5Clin. Universitaires St Luc Brussels Belgium, 6Calgary University Alberta Canada, 7UZ Gent Ghent Belgium Introduction and Aims: All guidelines recommend an arteriovenous fistula (AVF) as preferred bloodstream access. Still, many patients in Europe receive haemodialysis (HD) via a permanent catheter. This ERBP initiated study explored potential barriers related to attitude, organisation and reimbursement that may explain non-adherence to this fistula-first (FF) policy. Methods: We developed an electronic survey with 35 items regarding factors potentially affecting choice and quality of HD access. Via national renal societies, we invited 61 experts from 37 countries in the ERA-EDTA community to provide national data on access preference, care delivery and reimbursement. Results: In total, 44 experts (72% response rate) from 33 countries participated. The majority were nephrologists (89%) from public centres (86%) with ≥15 years of clinical experience (75%). Attitude Many respondents (84%) believed that a FF policy was justified by the current evidence base. However, only 36% expected an AVF to be a durable access in >80% of prevalent HD patients. When being presented different clinical cases, experts from 29 countries indicated that an AVF would be attempted in >80% of 40-yr old patients without comorbidities. In 9 countries this was believed to be the case in 75-yr olds with comorbidities. A FF policy was promoted in 23 countries. Organisation Centralisation of HD access care was formally facilitated by service providers in 4 countries; this was informally arranged by groups of centres in 18 countries, and not at all in 11. The time between the request and the actual procedure for AVF creation was longer than for catheter placement in 21 countries and similar in 12. In many countries nephrologists were among those responsible for placing catheters (n=24), but this was seldom so for creating AVFs (n=7). Educational meetings on HD access were organised in 27 countries; 2 provided certified training. In 17 countries there was a formal multidisciplinary approach to HD access care in at least part of the centres. Reimbursement In 19 countries facilities received a fee per created access. In 13 of them the fee for AVF creation was higher than for placing permanent catheters; in 5 this fee was paid directly to clinicians. Conclusions: Our study showed a positive overall attitude towards a FF policy, which became less apparent when applied to older and sicker patients. Future guidelines should thus be more specific about which patients could benefit from this policy. Reimbursement seemed to favour AVF. Besides limited access to dedicated and certified clinicians to create AVFs, we identified lack of formal care centralisation as a potential organisational barrier. Encouraging collaboration in HD access care might be warranted.
SO062
HEMODIALYSIS TUNNELED CENTRAL VENOUS CATHETERS: FIVE YEARS OUTCOMES ANALYSIS
Salvatore Mandolfo1, Pasqualina Acconcia1, Raffaella Bucci1, Bruno Corradi1 and Marco Farina1 1 Renal Unit - A.O. Lodi Lodi Italy Introduction and Aims: Tunnelled central venous catheters (TCVC) are considered inferior to fistulas and grafts in all nephrology guidelines. However, they, are being increasingly used as haemodialysis vascular access. The purpose of this study was to document the natural history of TCVC to determine the rate and type of catheter replacement. Methods: This was a prospective study of patients who are undergoing hemodialysis (HD) with TCVC on our renal unit between January 2008 and December 2012. Standard protocols, according to European Renal Best Practice (2007, 2010), detailing all aspects of preventive nursing care, early diagnosis, were well established. All catheters were inserted in the internal jugular vein (right 91 %). Complete data was available on 141 patients (age 73 ± 10 year) who used 154 TCVC. Criteria for catheter removal were (1) persistent bloodstream infection (repetitive blood culture 1 week after completation of antibiotic therapy); (2) detection of an outbreak of CRBS; or (3) catheter dysfunction (inadequate blood flow rate - Qb < 250 ml/min) for three consecutive treatments. Event rates were calculated per 1,000 catheter days; TCVC cumulative survival was estimated according Kaplan Meier analysis.
Results: Catheter replacement occurred in 15 patient (0.29 per 1,000 days), catheter dysfunction with loss of patency was the main cause of replacement (0.18 per 1.000 days), typically within 12 months of catheter insertion. A total of 53 CRBS events in 36 patients were identified (0.82 per 1,000 days) There were 17 organisms isolated. The most common organisms were Gram-positive, comprising 62% of all species. Among Gram-positive pathogen isolated, most frequently were the Staphylococcus Epidermidis of which 87% MRSE, the Enterococcus of which 85% E. faecalis, the Staphylococcus Aureus of which 14% MRSA. Among Gram-negative (58% ESBL positive) most frequently were pseudomoniacee and enterobacteriacee. The vast majority of CVC infections (87%) were cleared by systemic antibiotics associated with lock therapy. TCVC cumulative survival was 91% at 1 year, 88 % at 2 years and 85 % at 4 years. Conclusions: Our data showed an high survival rate of TCVC in patient undergoing HD, with low incidence of catheter dysfunction and CRBS. Careful application of standard protocols in the dialysis staff contributed to achieve this results. These data justify TCVC use for hemodialysis vascular access, even as a first choice, especially in patients with exhausted peripheral access, abrupt failure or lack of a native arteriovenous fistula and in patientswith limitedlife expectancy.
SO063
A RANDOMISED CONTROL TRIAL OF TAUROLIDINE-HEPARIN-CITRATE LINE LOCKS IN PREVENTION OF RECURRENCE OF CATHETER RELATED BACTERAEMIA IN HAEMODIALYSIS PATIENTS
Richard Corbett1, Damien Ashby1, Claire Edwards1, Virginia Prout1, Seema Singh1, Rachna Bedi1 and Neill Duncan1 1 Imperial College Renal and Transplant Centre Hammersmith Hospital London United Kingdom Introduction and Aims: Catheter related bacteraemia (CRB) is a cause of significant morbidity in patients maintained on long-term tunnelled haemodialysis catheters for vascular access. Catheter salvage (antibiotic treatment without removal of the catheter) is advocated for individuals without signs of systemic sepsis, who have a favourable initial response to antibiotics. The study was designed to assess the hypothesis that taurolidine-heparin-citrate (THC) line locks are superior to heparin in preventing recurrence of CRB. Methods: An open-label parallel-group randomised controlled trial was designed comparing THC (containing heparin 500units/ml) against heparin (5000units/ml) line locks. All patients on established haemodialysis within our in-centre and satellite dialysis units, with evidence of a CRB and who had commenced treatment for catheter salvage were considered eligible. Patients were randomised within two weeks of a bacteraemia to either THC or heparin line locks following each dialysis for 6 months, in addition to standard antibiotic therapy. The pre-specified primary outcome measure was bacteraemia free catheter survival. (Clinical Trial No: NCT01243710). Results: 27 patients were recruited to the study with 13 patients randomised to heparin and 14 to THC. A significant difference in the primary outcome measure was seen with improved catheter survival in individuals receiving THC ( p=0.009). No recurrence of CRB occurred in the THC group, while 5 catheters were removed in the heparin group during the six month trial period. The trial size was too small to meaningfully interpret pre-defined secondary outcome measures, though there was an increased thrombolytic use in the THC arm. Conclusions: Despite the small study size, THC line locks appear to be beneficial in the prevention of recurrence of CRB. It is uncertain whether this is at the expense of catheter dysfunction at a later point. THC line locks should be used as an adjunctive therapy in the setting of catheter salvage, while their role as a standard line lock remains unclear.
SO064
IS FETUIN-A A BIOMARKER OF VASCULAR ACCESS (VA) FUNCTION IN CHRONIC HEMODIALYSIS (HD) PATIENTS?
Ramon Roca-Tey1, M. Ramírez de Arellano2, J.C. González-Oliva1, R. Samon1, O. Ibrik1, A. Roda1 and J. Viladoms1 1 Nephrology Hospital de Mollet Mollet del Vallès Barcelona Spain, 2Nephrology Hospital de Terrassa Terrassa Barcelona Spain Introduction and Aims: The objective monitoring of VA function should be performed by measuring the blood flow (QA) (EBPG-2007). We have previously reported that the VA function is impaired (lower QA values) in patients ( pts) with medial histological calcifications on the feeding artery (CKJ 2008; 1suppl 2: ii352). On the other hand, fetuin-A is a potent inhibitor of vascular calcification and, according to Chen et al (Am J Kidney Dis 2010; 56:720), is a predictor for VA patency. The aims of this prospective observational study were to investigate the relationship between serum
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Abstracts
Nephrology Dialysis Transplantation
fetuin-A and Q values at baseline and the association between baseline serum fetuin-A levels and VA failure (thrombosis or elective intervention for stenosis) during the follow-up of prevalent HD patients. Methods: During January 2011 we measured baseline serum fetuin-A levels (ELISA) from 64 pts (age 66.5 ± 15.1 yr, diabetes 25 %) who underwent chronic HD through arteriovenous fistula (85.9 %) or graft (14.1 %). The same week of fetuin-A determination, the VA function was evaluated measuring the QA by the Delta-H metod using the Crit-Line III monitor. During the follow-up period (lasted until August 31, 2012), the QA was measured at least every 4 months and all VA with absolute QA< 700 ml/min or decreased > 20 % over time from baseline were referred for angiography plus subsequent elective VA intervention if VA stenosis > 50%. Results: At baseline, serum fetuin-A and QA values averaged 0.95 ± 0.62 g/L and 1156.3 ± 604.8 ml/min, respectively. Pts with baseline QA < 700 ml/min (n= 14) showed lower baseline fetuin-A levels (0.45 ± 0.11 g/L) compared with the remaining pts (1.09 ± 0.63 g/L) ( p < 0.001). According to fetuin-A levels, the pts were classified in Group I (0.25-0.75 g/L: n = 36, mean 0.48 ± 0.11 g/L) and Group II (0.76-2.20 g/L: n = 28, mean 1.56 ± 0.46 g/L). Pts in Group I showed lower baseline QA (1060.1 ± 685.1 ml/min) compared with pts in Group II (1279.9 ± 465.6 ml/min) ( p = 0.022). Fetuin-A was positively correlated with QA at baseline (Spearman correlation coefficient = 0.311, p = 0.012). During the observation period (345.9 ± 202.4 days), 21.9 % (n = 14) pts underwent VA failure (thrombosis: n = 9 or elective VA intervention for stenosis: n = 5). Pts with VA failure showed lower fetuin-A (0.59 ± 0.32 g/L) and lower QA (739.4 ± 438.8 ml/min) values at baseline compared with the remaining pts (1.05 ± 0.65 g/L and 1273.0 ± 596.3, respectively) ( p = 0.027 and p < 0.001, respectively). Kaplan-Meier analysis showed that pts in Group I tended to have lower primary unassisted VA patency compared with pts in Group II (long rank test, p = 0.070). Conclusions: 1) The functional VA profile is related to serum fetuin-A levels at baseline. 2) Lower serum fetuin-A levels at baseline are associated with VA failure during the follow-up.
SO065
VASCULAR ACCESS CALCIFICATION RATHER THAN OVERALL CALCIFICATION SCORE IS A PREDICTOR OF ARTERIO-VENOUS FISTULA SURVIVAL
Aleksandar Jankovic1, Tatjana Damjanovic1, Zivka Djuric1, Jovan Popovic1 and Nada Dimkovic1 1 Clinical Department for Renal Diseases with Dialysis Zvezdara University Medical Center Belgrade Serbia and Montenegro Introduction and Aims: Functional, long-lasting vascular access (VA) is essential for maintaining effective long-term haemodialysis.It has been shown that the most reliable VA are autogenous arteriovenous fistulas (AVFs) as compared with arteriovenous grafts (AVG) and tunneled catheters. Given the importance of the role that AVFs have in maintenance of HD treatment, there is a constant need to find other causes of her failure/survival. Aim: Aim of this study was to determine factors that influence AVF survival. Methods: This retrospectrive study included 181 patients treated by chronic HD for more than 6 months. Patients with AVGs and vascular catheter as first VA and patients with primary failure of first AVF were excluded from further analysis. Beside general data analysis include the last data from the medical records at the time of investigation: HD vintage, characteristics of dialysis membrane, blood flow during HD, mineral metabolisam indices and the use (and dose) of vitamin D analogues. Blood flow rate during HD was less than 250 ml/min in 38 (23.2%) patients, 250 ml/min in 55 (33.5%) and above 250 ml/min in 71 (43.3%) consecutively.For scoring of the calcification we used Adragao score supplemented by the calcification score of VA region (ulnar artery, radial artery and shunt). Results: There were no significant difference in 1-, 5- and 10-year AVF survival in regard to age, underlying renal disease, vitD usage, presence of hypertension and diabetes, dyalysis membrane type, blood flow rate and serum Ca/P. Figure 1 and Table 1 show survival of first functional AVF in patients with different AVF calcification score which was statisticaly significant ( p=0.009). However, 1-, 5- and 10-year AVF survival was not influenced by overall calcification score (85.4%, 73.2% and 65.9% in patients with score from 0 to 3; 96.8%, 74.1% and 67.3% in patients with score from 4 to 7 and 87.1%, 74.2% and 63.2% in patients with score from 8 to 11; p= 0.614). Results of multivariate logistic regression have shown that only serum PTH over 650 pg/mol is independent factor that influence survival of AVF ( p=0.026, OR=0.134). Conclusions: Our study has shown that more prominent vascular access calcification score have protective effect on first functional AVF. In spite of traditional opinion, our research has shown that high iPTH level is an independent factor that influence on AVF survival rate.
SO065 Figure 1:
SO066
SERUM SCLEROSTIN LEVELS, ARTERIOVENOUS FISTULA CALCIFICATION AND ARTERIOVENOUS FISTULA SURVIVAL IN PREVALENT HAEMODIALYSIS PATIENTS
Alper Kirkpantur1, Aysel Turkvatan2, Mustafa Balci3, Ismail Kirbas4, Sibel Mandiroglu5, Baris Afsar6 and Fahri Mandiroglu1 1 Nephrology RFM Renal Tedavi Hizmetleri Ankara Turkey, 2Radiology Yüksek Ihtisas Hastanesi Ankara Turkey, 3Cardiology Yüksek Ihtisas Hastanesi Ankara Turkey, 4Interventional Radiology Fatih University School of Medicine Ankara Turkey, 5Physical Therapy and Rehabilitation Ankara Fizik Tedavi Ve Rehabilitasyon Hastanesi Ankara Turkey, 6Nephrology Konya Numune Hastanesi Konya Turkey Introduction and Aims: Arteriovenous fistula (AVF) is prone to recurrent stenosis and thrombosis. Sclerostin, a novel protein secreted by the osteocytes, has been recently shown to be associated with renal osteodystrophy. This prospective study was to designed to determine if there was an association between serum sclerostin levels, AVF calcification and one year AVF survival. Methods: 350 haemodialysis patients were involved and followed for 12 months. AVF calcification was evaluated by computed tomography as described previously by Agatston et al. AVF surveillance was conducted by clinical and ultrasonographic evaluation. AVF dysfunction is diagnosed on angiographic basis. Results: Patients with calcified AVFs had higher serum sclerostin levels than patients with not (1841±1516 vs 1261±1173 pg/ml; p=0,002). Serum sclerostin levels was correlated with AVF calcium score (r=0,417, p=0.002).One-year AVF survival was reduced in patients with calcified AVFs (HR for AVF thrombosis: 1.20; 95‰ CI, 1.12– 1.38; p=0.030).Patients with 25–hydroxy D3 levels greater than median value (21,6 microgr⁄L; Group 1) were associated with an increase in AVF survival, compared to patients with 25–hydroxy D3 levels greater than median value and receiving calcitriol (Group 2), patients with 25–hydroxy D3 levels lower than median value and receiving
SO065 Table 1. Vascular access calcification score 1- year survival 5- years survival 10- years survival 0 1 2 3
i | Abstracts
88.9% 87.9% 90.5% 92.3%
77.8% 60.6% 75.9% 92.3%
68.9% 56.8% 54.8% 92.3%
SO066 Figure 1:
Volume 28 | Supplement 1 | May 2013
Nephrology Dialysis Transplantation
Abstracts calcitriol (Group 3) and finally patients with 25−hydroxy D3 levels lower than median value and not receiving calcitriol (Group 4)(Log rank: p
