Optimising vascular access in incident haemodialysis patients

RD Surgery

Aitken, Emma L ; Kingsmore, David B.

University:University of Glasgow

Department:Institute of Cardiovascular and Medical Sciences

关键词: Vascular access, haemodialysis, arteriovenous fistula, arteriovenous graft.;   

Others  :  http://theses.gla.ac.uk/8075/7/2017AitkenPhD.pdf

来源: University of Glasgow

【 摘 要 】

Arteriovenous fistula (AVF) are widely considered to be the optimal form of vascular access for haemodialysis incurring fewer complications, superior patency, better dialysis quality and a lower mortality than tunnelled central venous catheters (TCVCs). The use of TCVCs is associated with a six-fold increase in the risk of systemic sepsis, long-term morbidity from central vein stenosis and a higher risk of cardiovascular and all-cause mortality compared to AVF. Despite the relative success of strategies such as “Fistula First” and the best practice target in England and Wales (with simultaneous improvement in prevalent autologous access use) there has been no associated improvement in incident vascular access rates.The importance of “getting it right from the start” cannot be overemphasized. Patients who start dialysis via a line are more likely to remain with a line. Data from the UK Renal Registry indicate that 59.8% of patients starting on a TCVC remain dialysing via a TCVC at 3 months and >40% still have their TCVC after 1 year. The legacy of poor early vascular access decision-making remains with the patient throughout their life on dialysis. This thesis sought to evaluate methods for improving vascular access within the incident patient cohort. A multifaceted approach was taken to address several key themes: 1. TCVC complications and central vein stenosis: avoiding problems for the future. 2. Predicting maturation in incident dialysis patients. 3. Promoting maturation: strategies to optimise maturation. 4. Right access, right patient, right time: individualised, patient-centred care. 5. ‘Crashlanders’: managing patients who present without prior warning. The emphasis of this work was directed towards finding pragmatic, patient-focussed solutions to clinically relevant problems. The dogma of “Fistula First at all costs” is challenged.