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    Developing a Vascular Access Service as part of Pre-dialysis Education Program

    A guide for nephrology services providing maintenance haemodialysis

    As a part of the International Society of Nephrology CME held in Medicity Hospitals in Gurgaon, Delhi, India organised by the India-UK Renal Sister Centre program this document was created to help organisations to develop a new vascular access service in hospitals providing maintenance haemodialysis. This document is aimed for hospitals not only in India but similar hospitals in other countries with similar healthcare systems. The contributors included Nephrologists, Dialysis experts, Transplant & vascular access surgeons/Vascular surgeons and Renal Nurses. The document was created during a workshop and after several presentations on different aspects of vascular access creation and maintenance. Dialysis in IndiaIt is estimated that around 60,000-70,000 patients were on renal replacement (RRT) in India and the numbers are growing.  Approximately 90% of these are on haemodialysis and 10% on peritoneal dialysis. Most of these patients were not aware of their RRT options prior to starting dialysis due to lack of education about their chronic kidney disease. The initiation of dialysis was very rarely planned and thus the majority patients started dialysis with temporary lines. There were no pre dialysis CKD clinics and vascular access service in most hospitals including the host hospital in Delhi. 


    Advanced or Predialysis CKD Clinic

    Preparation of patients for renal replacement therapy is key for starting dialysis with permanent vascular access given improved outcomes on dialysis. The vascular access team could provide in-reach service at the CKD clinic, including education on creation, maturation and maintenance of dialysis vascular access.  Education on renal replacement therapy on haemodialysis, peritoneal dialysis and kidney transplantation helps patients make an informed decision on the type of RRT they choose. Well- trained nurses are best placed to provide individual and small group education sessions on RRT.  The Vascular access specialist nurses can provide education at induction and continue to be their advocate in planning dialysis initiation and vascular access. 

    Aims of the advanced CKD clinic This will be led by CKD Nurse, Vascular Access Nurse and Nephrologist and the aim will be to provide education on and manage the following:

    1. Complications and progression of CKD 
    2. Renal anaemia and CKD mineral bone disease
    3. Options for renal replacement therapy
    4. Options for dialysis access in time for maturation before the start of haemodialysis 
    5. Diet in renal disease
    6. Tests for Hepatitis B and C and immunization for Hepatitis B

    Vascular access service and clinics

    A vascular access service is essential for good health of patients in maintenance haemodialysis. Evidence demonstrates that patients starting dialysis with permanent vascular access, particularly a fistula suffer fewer infections, hospital admissions, fewer central access problems and have better survival (Ravani et al 2013 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582202/).

    It also decreases the cost of providing dialysis. Thus planning and creation of a fistula before starting dialysis should be the goal for all patients starting haemodialysis. A distal radio-cephalic AV fistula should be considered as the first choice for all patients, unless the vessels are unsuitable, in which case the preferred choice may be a fistula in the upper arm. Patients staring dialysis with catheters should be encouraged to have a permanent access as soon as possible. Patients who need to dialyse with long term catheters, such as patients non-suitable for a fistula, need excellent access care to avoid infections and hospital admission but there are clear limitations to this approach. Monitoring of access during dialysis is essential to ensure longevity of the access and may be done by simple measures such as clinical examination, monitoring of venous pressures during dialysis or by flow monitoring. Problems identified should be dealt with urgently via the vascular specialist nurse. Access to an on-going training program should exist for vascular access nurses, junior and senior surgeons, junior and senior nephrologists, radiologists and dialysis nurses. It may be appropriate to provide these programs regionally rather than in each renal unit.

    Every dialysis unit should have access to a vascular access team comprising vascular access nurse, dialysis physician, vascular surgeon and interventional radiologist. The patient and the vascular access nurse should be at the centre of this service. 

    The vascular access specialist nurses will 

    1. Provide initial education on vascular access
    2. Plan the timing of creation of permanent access before dialysis
    3. Organize venous and arterial mapping in preparation for fistula formation
    4. Refer the patient to the vascular surgeon
    5. Follow the patient after creation of a fistula
    6. Guide first needling of the fistula at the start of dialysis
    7. Liaise with dialysis nurses regarding the results of monitoring
    8. Organise sessions with the interventional radiologist if necessary
    9. Contact the vascular surgeon for rescue operation

    Protocol for patient management in the vascular access clinic pre and post operative period

    1. Every patient will get an ultrasound scan for vein and artery mapping
    2. Size of vein and artery should be minimum 2 mm at wrist and elbow
    3. Follow up after fistula creation will be at 2 weeks. Some patients may need to come 2-3 days after surgery at surgeon’s discretion
    4. Needling of AVF will be done at or after 6 weeks
    5. Initial needling will be done by a trained technician or vascular access nurse
    6. In case of difficulty, ultrasound guided needling will be done.
    7. The technician shall contact the vascular access nurse in case of problem in needling of AVF.
    8. Vascular access nurse will contact the surgeon if problem persists
    9. A radiologist/vascular surgeon will do the angioplasty when required.
    10. Patient will contact the vascular access nurse in case of suspected non-functional AVF.
    11. Monitoring of functioning access may be clinical with measurement of flow if available.

    Figure 1: The vascular access service with the nurse as the coordinator 


    Patient pathways

    From CKD clinic: The patients will be referred to the vascular access service in a timely fashion which will be by the CKD Nurses or Nephrologist. The patients will then be managed by the vascular access speciality nurses who will coordinate the radiology and vascular surgery. This should be all arranged in one day under a Vascular access one stop clinic. See figure below



     
    From dialysis units: Patients from chronic dialysis units without a working fistula should be identified by dialysis nurses and referred to the vascular access service. The vascular access nurse should see them on dialysis and provide education on the importance of proper access. The vascular nurse will then organise the vascular access mapping of arteries and veins and refer them to vascular surgeon. See figure 



    After acute fistula malfunction: Once a fistula malfunctions as evidenced by poor flows, poor dialysis, high venous pressures, clots or no flow, the dialysis nurses should inform the vascular access service. The vascular access speciality nurses will assess and plan either radiology or surgical procedures as needed in discussion with the vascular access surgeon. See Figure below

     

    Requirements for the Vascular surgery service, for 100 dialysis patients

     
    • Two surgeons
    • Theatre time 2 hours per week
    • Surgical time 4 hours per week
     

    Need for a radiology service

     
    • For initial vascular access mapping
    • For fistulogram and fistuloplasty
     

    Audit goals

    • Incident hemodialysis by AVF: 35%
    • Prevalent hemodialysis by  AVF: >50%
    • Clinic to theatre time 2 weeks or less
     

    Contributors

    Debasish Banerjee, Atul Bagul, Mysore K Phanish, Dinesh Bansal, Reetesh Sharma,
    Himanshu Verma, Dinesh Yadav, Iain  Macphee, Vijay Kher and Vivekanand Jha.