Università La Sapienza Scuola di Specializzazione in Nefrologia Prof P. Menè Meeting di Nefrololgia Interventistica L Accesso Vascolare Impossibile Roma 23 Marzo 2016 Il paziente anziano, evidenza e survey nazionale dr Carlo Lomonte U.O.C. di Nefrologia e Dialisi Ente Ecclesiastico Ospedale Miulli Acquaviva delle Fonti - Ba
The DOPPS (Dialysis Outcomes and Practice Pattern Study) is a prospective cohort study of hemodialysis practices based on the collection of observational longitudinal data
3 Pazienti incidenti Pisoni, AJKD 2015
Pazienti prevalenti 4 Pisoni, AJKD 2015
86% 68% www.dopps.org
68% 32% www.dopps.org
Fistula First Change Concepts The Change Concepts provide the roadmap to implement the KDOQI vascular access recommendations.
Interventional nephrology: a new area of competency in nephrology Organization (The American Society of Diagnostic and Interventional Nephrology ASDIN, was established on October 2000) Need (dysfunctional access was a major cause of patient morbidity and mortality) Interest (nephrologists have been trained to address all of the dialysis patient s problems. The exception was VA) G Beathard. History of interventional nephrology in the US In Asif et al: Interventional Nephrology. McGraw-Hill 2012
Academic Interventional Nephrology: A Model for Training, Research, and Patient Care There is a substantial need for the establishment of Academic Dialysis Access Centers (ADACs) These centers would be essential for transforming IN into a distinct discipline within nephrology similar to transplant nephrology Roy-Chaudhury et al, CJASN 2012
Roy-Chaudhury et al, CJASN 2012
vascular access costs 35% surgeons 30% radiologists 25% nephrologists 10% anesthesiology and other specialties Roy-Chaudhury, CJASN 2012
e in Italia?
Gruppo di Studio degli Accessi Vascolari 2000
Accessi vascolari prevalenti FAV nativa 83,9% FAV protesica 4,6% CVC cuffiato 11,5% Censimento SIN 2004
Who is the vascular access manager Nephrologist 48.8% Nephrologist and Vascular Surgeon 26.4% Vascular Surgeon 18.4% Others 6.4%
Nefrologo Chirurgo Vascolare Nefrologo + Chirurgo Vasc. Courtesy by Decenzio Bonucchi
68% www.dopps.org
Lack of dedicated training Limited routine use of preoperative diagnostic imaging Accessibility of surgical resources for creating fistulas Patients characteristics 18
CJASN 2013
Annual Report of ERA-EDTA Registry 2012 65-74 years = 22% >75 years = 20%
Timely VA placement in the elderly - Older patients lose renal function at slower rates than youngers one (Vachharajani, CJASN 2011) - The elderly patients may be more likely to die before benefiting from an AVF (Hod, JASN 2015) - The elderly patients with CKD should be referred later to reduce the risk of creating an AVF that is never used (Gomes, JASN 2013)
Hod et al, J Am Soc Nephrol 23 2015
VA in elderly patients: recent findings There is currently no general consensus as to the best dialysis VA for elderly patients with ESRD The creation and use of a VA in elderly patients requires the complex integration of patients, biological and surgical factors because the VA type might be a key factor influencing their survival
More vein, less plastic Criteria for the ideal VA device Safe Reliable performance and adequate blood flow Durable long-term function Internal Free from complications Acceptable to the patients Simple to create Inexpensive to create and maintain Vein preservation is paramount in patients who can be identified as being in the early stage of CRF A culture of vein preservation has to be developed in renal and surgical units and among venipuncture nurses, anesthetists etc. D Francis, Nephrology 2005 28
Detailed History Previous CVC (temporary or tunneled) Hospitalization for major events (trauma, ICU) Scars on the chest Previously failed VA Cardiac rhythm devices Swelling of the arm, shoulder, chest, brest, face Collaterals veins Salman & Beathard, CJASN 2013 29
Physical examination (summary) Presence of a superficial vein (straight of at least 8-10 cm) Good arterial pulse (not diminished or absent) Negative Allen s test (patent palmar arch) Difference < 10 mm Hg in blood pressure in 2 arms (normal) Asif et al, J Nephrol 2007 32 30
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The Necessity for Routine Pre-operative Ultrasound Mapping Before Arteriovenous Fistula Creation: A Meta-analysis Giorgiadis et al, Eur J Vasc Endovasc Surg. 2015 Randomized clinical trial of selective versus routine preoperative duplex ultrasound imaging before arteriovenous fistula surgery. Smith, Br J Surg. 2014
Elsharawy, J Vascular Access 2006 33
Three steps in order to increase the pool of eligible patients can be individualized: 1) process of care, which includes three fundamental items: - the VA team - early VA education - timely VA surgical referral 2) preoperative evaluation 3) surgical strategy 34
Surgical strategy in elderly patients
Primary failure - A recent meta-analysis examining studies from 2000 to 2012 reported a primary failure rate (defined as non usable AVF for dialysis up to 6 months post creation) of 23 % (Al-Jaishi, AJKD 2014) - AVF failure increases by 1% for every year above the age of 67 years (Hod, Hemodial Int 2014) - Patients over 65 years have a fistula failure rate double that of younger patients (Lok, JASN 2006)
Clinical use of the score system Lok, JASN 2006
» All patients with risk factors for central venous stenosis should have a venogram regardless of score Lok, JASN 2006 38
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Masengu, CKJ 2016 40
J Vasc Surg 2007 41
An Italian perspective AVF still remains the dialysis access with highest prevalence also in older patients, with an excellent survival rate (Venturelli et al JN 2013; Pirozzi et al JVA 2014) In Italy, among patients with > 4 months pre- ESRD care prior to starting chronic HD, 71% had AVF (DOPPS)
Ethier et al, NDT 2008
Conclusion we believe that dialysis VA selection in the elderly should be guided by patient s preference and surgeon s experience, based on comprehensive, balanced and unbiased information, adopting an individualized approach that strives to achieve the best outcomes regardless of age.
Key messages 1. Renal replacement therapy in the elderly raises several issues. 2. The VA planning in the elderly is different from that in younger patients: elderlies could be referred later to reduce the risk of creating an AVF that is never used. 3. The elderly with limited life expectancy may be less likely to benefit from an AVF first approach. 3. The patient s preference for the type of VA should be taken into account. 4. We advice to adopt an individualized approach, regardless of age.
CATETERE long term FAV DISPERATA Revisione FAV PROTESICA FAV PROTESICA Superficializzazione/Trasposizione V.nativi FAV PROSSIMALE FAV Prossimalizzata Riabbocco FAV DISTALE FAV DISTALE CVC TEMPORANEO - Il nefrologo ha sempre titolo per fare gli accessi!? F.G.