RBT Roundtable: Vascular Access

Vascular access is an essential component of a kidney disease patient’s dialysis care. It literally connects patients to the dialysis machine to clean their blood. It can also pose a problem for patients’ health with infection, which, in turn, can be costly for the healthcare system due to hospitalization. Enter the vascular access outpatient clinic. These clinics hope to change the renal care landscape by decreasing costs and improving the health of patients by treating vascular access directly and not as an afterthought.

Therefore, Renal Business Today asked some of the leaders in vascular access their thoughts on the role their clinics play in healthcare. Below is a roundtable discussion that includes Albert D. Sam II, MD, FACS, a vascular surgeon at Baton Rouge, La.-based Vascular Surgery Associates and clinical assistant professor at Louisiana State University Health Sciences Center; Janet R. Dees, president of American Vascular Access; Robert Kraus, vice president of marketing and sales with Vascular Access Centers, and Aris Urbanes, MD, vice president of provider relations with Lifeline Vascular Access. The U.S. Vascular response includes Deborah Wells, Business Unit president; Denise Sellars, RN, CDN, vice president of Quality; Ernest Gutierrez, director of Operations; Steve Fiander, vice president of Market Development.

Is the renal community doing a good job with vascular access?

Sam: Significant variation exists regarding the approach to vascular access regionally and thus underscores the main factor determining the quality of care rendered. Communities where nephrologists enjoy a collaborative, proactive relationship with surgeons that have embraced vascular access usually provide the best care to these challenging patients. Generally, this principle is gaining momentum in the U.S. and hopefully improved outcomes will be the end result. Besides the obvious benefits seen in efficiency, there are several reasons why collaboration across specialties in delivering care for access patients has been more present in recent times: More vascular fellowship trained surgeons are performing access procedures than in previous years and thus vascular access (and its inherent complicating issues) fits better in the workflow of these practices rather than in the general or transplant surgeon’s practice; more communities have freestanding access centers focused solely on the treatment of access patients; and the incidence of renal failure continues to increase requiring all practitioners to develop algorithms and systems to efficiently handle this increasing patient population.

Urbanes: Since the Fistula First Breakthrough Initiative was introduced in 2005, there has been a noticeable and significant increase in prevalent patients dialyzing with AV fistulae, although this remains below the target 65 percent rate nationwide. Certainly, there is greater awareness in the general renal community of physicians, nurses, technologists and patients of the superiority of fistulae over grafts and catheters. Nephrologists, nurses and dialysis staff, including patient care technicians, social workers and dieticians, and peer resources have been instrumental in educating patients regarding AVF creation and in particular, early placement in anticipation of the need for dialysis. Our surgical and radiology colleagues have likewise evolved in their involvement in and dedication to assuring that our patients have the best possible functional fistula. With the advent of interventional nephrology as a subspecialty of nephrology, we have been able to marry our general care of the nephrology patient, from pre-dialysis to dialysis and all its attendant complications, to the creation and maintenance of vascular access which remains the lifeline of our patients. What has previously been a poorly understood and woefully under treated problem of our patients now has greater awareness within the nephrology community, and consequently has problems recognized and treated earlier.

U.S. Vascular: In recent years there has been a growing initiative from the renal community to make sure that the dialysis patient has the best possible vascular access care. Although the renal community is still not at the threshold it is striving for, many industry product and service providers are developing various strategies to support and promote the increased use of autogenous fistulae. Both the National Kidney Foundation and the Centers for Medicare & Medicaid Services (CMS), along with the clinical nephrology community, have been instrumental in establishing specific guidelines for the creation and management of hemodialysis vascular accesses. Education and timely monitoring of end-stage renal disease (ESRD) patients are essential to achieving the goals of CMS and their Fistula First program. A continued collaborative effort of all in the community is necessary to enhance the quality care to the hemodialysis patient, which may also result in more efficient use of healthcare resources.

Dees: Yes, the renal community is doing a good job and has implemented a comprehensive plan in terms of improving vascular access via the programs of fistula first, surveillance and monitoring. Nurses and nephrologists have expressed their frustration in obtaining optimal access care for their patients. The cost and inconvenience of hospitalization has made this awareness acute.

The specialty of interventional nephrology emerged due to less than satisfactory access care and now CMS is moving to vascular centers for creation of fistulas by interventional nephrologists for better placement and care. We all know that an AV fistula is optimal but requires time to mature whereas many patients still present acutely or are too compromised for a fistula or graft so a catheter becomes the best alternative. In addition to the catheter all efforts to create and mature an AV fistula should be pursued or graft placement if warranted. Interventional nephrologists’ are the access MDs of choice as they are aware of the repercussions to the patient in terms of catheters, infections and hospitalizations.

Kraus: I believe the renal community is working to do a better job with vascular access. The Fistula First initiative has galvanized everyone to take the necessary steps to raise fistula placement. The ESRD Network data on vascular access (fistula creation) is improving every year. However there is still much work to be done as we still see significant number of catheters being used. That is why every dialysis programs need an access champions to direct the patients care and keep the vascular team focused on its mission.