EFFECTIVENESS OF MULTIMODAL INTERVENTIONS IN IMPROVING ARTERIOVENOUS FISTULA (AVF) USE OF NEW PLANNED HAEMODIALYSIS PATIENTS – A SINGLE CENTRE STUDY

PG TAN1, D LANGSFORD1, T PIANTA1, D BARIT1
1Northern Health, Epping, Australia

Aim: To evaluate if multidisciplinary interventions increase AVF use at time of planned haemodialysis initiation.
Background: The Victorian Key Performance Indicator (KPI) for commencement of planned haemodialysis with an AVF is 70%. In 2015, a multidisciplinary approach to improve fistula use at haemodialysis initiation was commenced: one-on-one chronic kidney disease education, use of vascular led arteriovenous ultrasound mapping and a combined nephrologist-vascular surgical AVF planning and triage clinic.
Methods: Patients commencing planned haemodialysis, AVF creation and prevalent use of permacath between 1/1/15 and 31/12/17 were retrospectively analysed. Quarterly KPI data from June 2015 to December 2017 was compared to state average. Patients that underwent pre-dialysis AVF creation were retrospectively stratified into low- or high-risk of dialysis need based on calculated 8-Variable Kidney Failure Risk Equation (KFRE) from demographic and renal specific data at time of vascular referral.
Results: Across the study period, 68 patients commenced haemodialysis whilst 85 underwent AVF creation. AVF use upon haemodialysis commencement consistently improved from 57% to 91%, compared to the statewide average of 56%-66%. Prevalent permacath rate fell from 18.3% to 10%.  Pre-dialysis AVF creation had increased from 74% to 85%. Amongst those who started dialysis with catheters, 50% had poor engagement with the Unit and 22% had late decision change regarding preferred dialysis modality. High-risk patients with KFRE score ≥20% had shorter waiting time for AVF creation (median 45 days(IQR95.75-294.25) vs 142days(IQR30-115), p-value <0.001) but no difference in time from access creation to dialysis commencement. There were no significant changes in patient characteristics over this period.
Conclusions: Multimodal interventions including joint assessment by nephrologists and vascular surgeons may improve triaging of patients and AVF use at haemodialysis commencement.


Biography:
Pek Ghe Tan is one of the Renal advanced trainee in Victoria. She is currently in her final year of training at the Northern Hospital.

A RETROSPECTIVE REVIEW OF ARTERIO-VENOUS ACCESS IN A SINGLE RENAL UNIT FROM 2010-2016

E CHUNG1, D KNAGGE1, L HEATH1, S CHEUNG1, H MCCOLL1, S MCGINN1, C FISHER1
1Royal North Shore Hospital, St Leonards, Australia

Aim: To review current practice and outcomes at a multi-centre renal unit with respect to decision making for haemodialysis access care.
Background: The gold standard of patients starting dialysis with a functional arteriovenous (AV) fistula is challenging, remaining static at around 40% in Australia.
Methods: A retrospective audit of AV access procedures on all patients requiring haemodialysis for more than 30 days at the Royal North Shore Dialysis Unit from 2010-2016 was performed combining Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), Australian and New Zealand Society for Vascular Surgery audit, Access Coordinator Database and electronic medical records.
Results: 561 patients received haemodialysis for more than 30 days. Of these 198 were already on haemodialysis and 363 started haemodialysis. During the 7 years, 169 (30%) died, 97 received transplants (17%) and 22 transferred to other units. In keeping with ANZDATA, 60% patients started haemodialysis with a central venous catheter. Although 94 (34%) had an established AV fistula, only 82 were usable. For 87 patients, AV access was placed after haemodialysis commenced. Of the 271 patients new to renal replacement therapy, 180 (66%) had 193 AV accesses placed and 156 patients used their AV access. 66 patients underwent 189 revisions including new accesses. Functional AV fistulae had been placed a median (interquartile range) of 144 (70-388) days prior to dialysis. Of note, 53 patients had 57 AV fistulae without needing dialysis within the review period.
Conclusions: A relatively low proportion of patients commencing dialysis have a functioning AV fistula with a high number of revisions being required. A need for an algorithm for non-maturing AV fistulae to guide timely surgical intervention is identified.


Biography:
Edmund Chung is currently a first year renal advanced trainee in the East Coast Network, NSW. He completed his undergraduate BMed MD at UNSW and postgraduate MMed (ClinEpi) at the University of Sydney. He has performed systematic reviews with the Cochrane Kidney and Transplant group and is passionate about better understanding how to limit the progression of chronic kidney disease.

ENDOVASCULAR THROMBECTOMY FOR SALVAGE OF CLOTTED VASCULAR ACCESS AND PREDICTORS OF POOR PATENCY FOLLOWING INTERVENTION

RY TAN1, S TEH1, S PANG1, A GOGNA2, T CHONG3, K LEE1, C TAN1
1Department of Renal Medicine, Singapore General Hospital, , Singapore, 2Department of Vascular and Interventional Radiology, Singapore General Hospital, , Singapore, 3Department of Vascular Surgery, Singapore General Hospital, , Singapore

Aim: We aim to report the outcomes of clotted vascular access salvaged using endovascular technique and investigate for predictors of poor patency following intervention.
Background: Endovascular techniques have been increasing used to salvage clotted hemodialysis vascular access.
Methods: We studied a retrospective cohort of incident patients who underwent salvage of clotted vascular access using endovascular technique from 1 March 2015 to 31 December 2017, determined the technical and clinical success rates and complication rates and investigated for predictors of poor patency following intervention.
Results: A total of 311 incident patients (mean age 63.8 ± 11.6) underwent endovascular thrombectomy during the study period. Of which, 53.7% were arteriovenous fistula (AVF) while 46.3% were arteriovenous graft (AVG). 96.5% of the interventions were successful radiologically but only 93.2% of patients had successful dialysis with the intervened access. Complications occurred in 31 (10%) interventions. Thrombosis-free survivals for AVF vs. AVG were 195.7 ±176 vs.145 ± 154.4 days respectively. (p=0.01). After adjusting for patient age, presence of diabetes mellitus, thrombolytic agent used and the use of cutting balloon, drug-eluting balloon and stents; AVG (adjusted OR 1.528, 95% CI 1.119-2.087, p 0.008) and prior thrombolysis within 90 days (adjusted OR 2.121, 95% CI 1.142-3.168, p <0.0001) were found to be significantly associated with poor patency post intervention.
Conclusion: Although most clotted vascular access can be successfully salvaged using endovascular techniques, long-term patency remains poor. Novel therapy should be explored to improve the long-term patency of vascular access post-thrombectomy.


Biography:
Dr Tan Ru Yu is a Consultant with the Department of Renal Medicine. She graduated with MBBS from International Medical University of Malaysia in 2005 and obtained Membership of the Royal College of Physicians (UK) in 2010. Dr Tan completed advanced specialist training in Renal Medicine 2014. Clinical interests include general nephrology, interventional nephrology, hemodialysis and critical care nephrology.

REASONS FOR DIALYSIS CATHETER INSERTION – REAL TIME PROSPECTIVE DATA FROM THE REDUCCTION PROJECT

S KOTWAL1,2, G TALAULIKAR3, N GRAY4, K POLKINGHORNE5, S MCDONALD6,  A CASS7, M GALLAGHER1,8
1Prince Of Wales Hospital, Sydney, Randwick, Australia, 2The George Institute for Global Health, Sydney, Australia, 3Renal Services, ACT Health, Canberra, Australia, 4Sunshine Coast University Hospital, Birtinya, Australia, 5Monash Medical Centre, Melbourne, Australia, 6ANZDATA Registry, Adelaide, Australia, 7Menzies School of Health Research, Darwin, Australia, 8Concord Clinical School, University of Sydney, Sydney, Australia

Aim: Understand the reasons for dialysis catheter insertion in patients of Australian renal units participating in a prospective national project (Reducing the burden of dialysis catheter complications – REDUCCTION).
Background: Dialysis catheters are inserted for reasons which are not well measured or understood. Understanding reasons for catheter insertion on a real-time basis allows units to measure practice and catheter use in a national context.
Methods: Data was collected using a web-based data collection tool on all patients who had a dialysis catheter inserted between 20/12/2016 and 23/03/2018 (censored) at any of the 37 units participating in the REDUCCTION project. The reasons for insertions were grouped into Acute Kidney Injury (AKI), commencement of maintenance dialysis, arteriovenous fistula/graft (AVF/AVG) dysfunction, transition from Peritoneal Dialysis (PD) without permanent vascular access and other as reported by study site.
Results: Data on 3572 (2522 patients) dialysis catheters were captured, representing 316,039 catheter days. Of these, 1176 (32.5%; 60% Tunnelled) catheters were inserted for AKI, 1047 (29.4%; 85.8% tunnelled) for commencement of maintenance dialysis, 464 (13%) for AVF/AVG dysfunction, 401 (11.3%) for transition from PD and 481 catheters (13.5%) for other reasons. Twenty-nine catheters were inserted in 27 patients for failing renal transplants. A total of 1075 catheters remained in situ at the censor date while 2497 catheters were removed after a median of 18 days (IQR 6-71 days). The median duration for tunnelled catheters was 75 days (IQR 26-170) and non-tunnelled catheters was 6 (IQR 3-9) days.
Conclusion: The data suggest opportunities to reduce catheter usage by understanding patients with AKI requiring dialysis better, identifying those starting chronic HD in a timely fashion and better managing the transition from PD.


Biography:
Dr Kotwal is a nephrologist at Prince of Wales Hospital in Sydney Australia and a post-doctoral research fellow at the George Institute of Global Health. Her main area of interests lie in the use of linked health data and evidence implementation research.She has a background in epidemiology, biostatistics and the analysis of linked health data. She has designed and led multiple data linkage projects across Australia and has experience in analysis of large observational registry and administrative datasets.

A SURVEY OF DIALYSIS CATHETER MANAGEMENT PRACTICES IN AUSTRALIAN AND NEW ZEALAND

B SMYTH1,2, S KOTWAL1,3, M GALLAGHER1,4, N GRAY5,6, K POLKINGHORNE7, on behalf of the REDUCCTION Trial Group
1The George Institute for Global Health, UNSW, Sydney, Australia, 2Sydney School of Public Health, University of Sydney, Sydney, Australia, 3Prince of Wales Hospital, Sydney, Australia, 4Concord Clinical School, University of Sydney, Sydney, Australia, 5Sunshine Coast University Hospital, Birtinya, Australia, 6Sunshine Coast Clinical School, University of Queensland, , Australia, 7Monash Medical Centre, Monash University, Melbourne, Australia

Aim: To describe dialysis catheter management practices in dialysis units in Australia and New Zealand.
Background: Dialysis catheter associated infections (CAI) are a serious and costly burden on patients and the healthcare system. Many approaches to minimising catheter use and infection prophylaxis are available and the practice patterns in Australia and New Zealand are not known.
Methods: Online survey comprising 51 questions, completed by representatives from dialysis units from both countries.
Results: Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 79% of the dialysis population in both countries. Nephrologists (including trainees) inserted non-tunnelled catheters at 60% and tunnelled catheters at 31% of units. Prophylactic antibiotics were given with catheter insertion at 21% of units. Heparin was the most common locking solution for both non-tunnelled (77%) and tunnelled catheters (69%), with antimicrobial locks being predominant only in New Zealand (80%). Eight different combinations of exit site dressing were in use, with an antibiotic patch (35%) and sterile dressing alone (31%) being most common. All units in New Zealand and 84% of those in Australia undertook CAI surveillance. However, only 51% of those units were able to provide a figure for their most recent rate of catheter associated bacteraemia per 1000 catheter days.
Conclusions: There is wide variation in current dialysis catheter management practice and evidence suggests that CAI surveillance is suboptimal. Increased attention to the scope and quality of CAI surveillance is warranted and the variation in practice suggests further work is required to better define the standard of care.


Biography:
Dr Smyth is a nphrologist and PhD candidate at The eorge Institute for Global Health. His research interests include dialysis, especially randomised controlled trial methodology and evidence as well as patient reported outcomes in dialysis patients.

DISTANCE TO A RURAL RENAL SERVICE AND INITIAL ACCESS IN HAEMODIALYSIS

T YOUNG1,2,4, L PHIPPS3,4
1Bathurst Base Hospital, Bathurst, Australia, 2Lithgow Hospital, Lithgow , Australia, 3Orange Health Service, Orange, Australia, 4University of Sydney, ,

Aim: To review type of initial access in patients commencing haemodialysis (HD) in a regional setting in relation to their geographic location.
Background: An arteriovenous fistula (AVF) is the gold standard for initial access in HD(1). The challenges in our regional setting include access to specialist vascular surgeon input and distance to both our facility and tertiary facilities.
In response to an audit revealing high rates of CVC use in our facility we developed a multidisciplinary strategy (involving recruitment of visiting vascular surgeon, patient education and dedicated vascular ultrasonography) to ensure timely AVF formation. We then audited this strategy.
Results: 105 cases were analysed.There was a statistically significant increase in patients commencing HD with an AVF after implementation of our strategy.
The data also revealed patients commencing with a CVC had a tendency to live further from our centre than patients with an AVF (76.0km vs 41.52km), and had a greater number of hospitalisations.Patients with a CVC had higher mortality rates at the end of the first year of HD compared to patients with an AVF(17.8%vs 10.8%).
Conclusion: We demonstrated greater numbers of patients commencing HD with an AVF following implementation of a multidisciplinary approach.
CVC use was more common in patients with a greater distance to travel to access our service, indicating that travel time may be a barrier to optimal care. CVC use was associated with higher number of hospitalisations and mortality in our cohort. Future service development should focus on enabling equitable service provision for all patients, regardless of their geographic location.1)KHA-CARI Guidelines: Polkinghorne et al Nephrology 2013;18(11):701-5.


Biography:
Dr Tamara Young is an Endocrinologist and General Physician. She has a strong interest in Nephology, and spent one year working as a renal registrar in Orange in 2017; whilst completing advanced training in general and acute care medicine. She works as an endocrinologist at Bathurst and Lithgow hospitals and does outreach clinics to Bourke and Brewarrina. In 2018 she also commenced research at The George Institute for Global Health

EFFECTS OF FISH OIL SUPPLEMENTATION AND ASPIRIN USE ON THE NEED FOR ARTERIOVENOUS FISTULA INTERVENTIONS AND CENTRAL VENOUS CATHETERS IN PATIENTS REQUIRING HAEMODIALYSIS

A VIECELLI1,2, E PASCOE2, C HAWLEY1,2, K POLKINGHORNE3, T MORI4, D JOHNSON1,2, A IRISH4
1Princess Alexandra Hospital, Brisbane, Australia, 2University of Queensland, Brisbane, Australia, 3Monash Medical Centre, Melbourne, Australia, 4University of Western Australia, Perth, Australia

Aim: As part of the FAVOURED Study, we examined the effect of fish oil and aspirin on arteriovenous fistula (AVF) interventions and central venous catheter (CVC) use.
Background: Successful creation of an AVF is limited by early thrombosis and maturation failure requiring interventions and/or placement of CVC. These complications may be reduced by pleotropic effects of fish oil upon vascular biology and inflammation, and platelet inhibition by aspirin.
Methods: In 567 adult participants planned for AVF creation, all were randomised to fish oil (4g/d) or placebo, and 406 to aspirin (100mg/d) or placebo, starting 1 day pre-surgery and continued for 12 weeks. Pre-specified secondary outcomes included rates of rescue interventions for AVF thrombosis, non-rescue interventions, and the frequency and duration of CVC requirements within 12 months of access creation.
Results: The mean age was 55 years, 64% were male and 47% diabetic. Fish oil supplementation significantly reduced the overall rate of access interventions compared to placebo (0.82 vs 1.14 interventions/1000 patient-days, incident rate ratio [IRR] 0.72, 95% confidence interval [CI] 0.54-0.97, p=0.03), driven by a reduction in rescue interventions (0.09 vs 0.17 interventions/1000 patient-days, IRR 0.53, 95% CI 0.34-0.84). Similarly, low-dose aspirin significantly reduced rescue intervention rates (IRR 0.45, 95% CI 0.27-0.78) but not overall intervention rates (IRR 0.84, 95% CI 0.59-1.19). Half of the participants required a CVC and neither fish oil nor aspirin reduced the frequency or duration of CVC requirements compared to placebo.
Conclusion: Fish oil and aspirin given for 3 months both independently reduced intervention rates in newly created AVF but they had no significant effects on CVC requirements. Reduction in access interventions benefits patients, reduces costs and warrants further study.


Biography:
Dr Andrea Viecelli is a Nephrologist in Brisbane and enrolled in a PhD examining strategies for improving vascular access outcomes in patients on haemodialysis. She is a lead investigator in the FAVOURED study, an international, randomised controlled trial of fish oil and aspirin for preventing arteriovenous fistula failure. She is also a member of the Coordinating Committee for the global Standardised Outcomes in Nephrology (SONG) initiative, which aims to improve the relevance and reliability of evidence informing clinical decision-making by developing core outcomes across the spectrum of kidney disease based on shared priorities of patients, clinicians, researchers and policy makers.

CARDIOPULMONARY RECIRCULATION: AN UNDERRECOGNIZED CONTRIBUTOR TO HAEMODIALYSIS EFFECTIVENESS

T BETTLER2, L KAIRAITIS1,2
1Western Renal Services, Westmead, Australia, 2School of Medicine, Western Sydney University, Campbelltown, Australia

Aim: To investigate whether Cardiopulmonary Recirculation (CPR) impacts on the nutrition of haemodialysis (HD) patients due to potential effects on reduced dialysis effectiveness.
Background: Recirculation during HD impacts on dialysis effectiveness by impairing the ability of treated blood to equilibrate with tissue solute stores. Recirculation can occur within arteriovenous access (in the setting of low access flow (Qa)) as well as by CPR (determined by the relationship of Qa to cardiac output (CO)). The impact of CPR on measures of dialysis effectiveness and nutrition is largely unknown.
Methods: Stable patients undergoing maintenance HD in Western Sydney were identified; these patients have six-monthly Qa, recirculation and CPR measures as part of access surveillance using an indicator dilution method. Demographic details were collected in addition to biochemical markers (serum albumin, potassium, bicarbonate and haemoglobin). Albumin was chosen as a surrogate marker of patient nutrition and patient outcome.
Results: 180 patients were included. Low Qa (<500mL/minute) was found in 21 patients (12%), total recirculation >10% in 74 patients (41%) and CPR>30% in 62 patients (34%). There was no significant difference in biochemical markers for patients with low Qa (<500mL/min). Patients with high total recirculation (determined predominantly by CPR) and those with a CPR of >30% had significantly lower serum albumin (34g/L vs 31g/L, p=0.01 and p=0.02 respectively). Potassium, bicarbonate and haemoglobin levels did not differ between different recirculation groups.
Conclusion: Both CPR and total recirculation are potential contributors to patient nutrition and outcome likely due to their impact on dialysis effectiveness. CPR values should be taken into account when interpreting the results of vascular access performance measures and when prescribing maintenance haemodialysis.


Biography:
A/Prof Lukas Kairaitis is a nephrologist and university academic working in Western Sydney. He has clinical and research interests in haemodialysis and vascular access.

ARTERIO-VENOUS FISTULA OUTCOMES AND PREDICTORS OF PRIMARY FAILURE IN PATIENT CENTRED VASCULAR ACCESS MODEL

F NGWENYA1, DC-Y LIN1, TY-T SUN1, E LY1
1Counties Manukau Health, Auckland, New Zealand

Aim: We reviewed arterio-venous fistula(AVF) outcomes in a patient centred vascular access model and identify predictors of primary failure.
Background:A VF primary failure rates may benchmark clinical practice, but are not the sole determinant for evaluating vascular performance.  Our model considers premium anatomical choice against patient factors and optimising future fistula options.
Methods: Retrospective analysis of new AVF created at Counties Manukau Health 1stAugust,2016-30thJuly,2017. Follow-up completed 31stMarch 2018. AVF not needled or with planned second stage were excluded.  Primary end-points were primary failure (AVF dysfunction resulting in abandonment, requiring intervention prior to first use, used <8/12 dialysis sessions or requiring intervention within first 30 days of needling) and overall AVF patency at six months.  Secondary analysis reviewed fistula outcomes against patient characteristics, comorbidities, previous fistula, preoperative vein calibre (<3mm), perioperative surgical and post-operative fistula assessment by clinician.
Results: 85 patients included; 61% radio-cephalic, 38% bracio-cephalic/basilic, 1% other AVF.  Major ethnic group Pacific Island(54%), mean age(54years), 55% male, 67% diabetic, 19% atherosclerotic disease, 24% had previous fistula.  These factors did not affect AVF outcome.  Primary failure was 51%.  Overall patency 79% at six months – censored for death, transplant, lost follow-up.  On univariate analysis previous functional AVF (odds ratio OR 0.2;p=0.01), perioperative surgical (OR 7.6;p<0.001) and post-operative staff assessment (OR 58.6;p<0.001) were independently associated with AVF outcome. Composite analysis using vein calibre, perioperative surgical and post-operative clinician assessment provided greater accuracy OR 7.1, 33.3 and 129.0; if one, two or three positive respectively p=0.002.
Conclusion: This model produced high primary failure but acceptable overall patency.  Increased primary failure may be predicted by combining preoperative imaging, perioperative surgical and post-operative fistula assessments and may guide need for increased monitoring and early intervention.


Biography:
Fortune Ngwenya is the Counties Manukau Health Vascular Access Co-ordinator. He completed his Nursing Diploma from Mpilo School of Nursing, Zimbabwe and Postgraduate Nursing Diploma through Victoria University, Wellington. He has a thirteen year medical and renal nursing background from Mpilo Hospital and Canterbury District Health Board; and worked at Counties Manukau Health for the last seven years. Fortune has a special interest in improving vascular access outcomes and works closely with Nephrologists, Vascular Surgeons and Interventional Radiologists at Middlemore Hospital, Auckland New Zealand. He is working towards his Master of Nursing degree at Massey University, Auckland.

VASCULAR ACCESS IN PATIENTS COMMENCING HAEMODIALYSIS – RESULTS OF IMPLEMENTATION OF A QUALITY IMPROVEMENT PROJECT

T YOUNG1 , M MANNING1, L PHIPPS1, K FOGO1

1Orange Health Service, NSW Australia

Aim: To review a QI project regarding initial access in patient commencing haemodialysis

Background: An arteriovenous fistula (AVF) is the preferred initial access in patients new to haemodialysis (1). For patients residing in our rural area, access to specialist vascular surgeon input , and distance to both our facility and tertiary facilities pose challenges in implementing best practice.

Method: An initial audit of access in patients commencing dialysis demonstrated high rates of central venous catheter (CVC) and arteriovenous graft (AVG) use . In the year preceding the intervention, initial access was via AVF in 2/15 cases, AVG in 1/15 cases and CVC in 12/15 cases.

A multifaceted, preemeptive approach was developed, utilising an skilled ultrasonographer, and patient education regarding access preservation . A vascular surgeon was recruited to visit our site on a monthly basis.

Results: In the three years following this intervention, the proportion of patients commencing access improved, with 7/8 patients commencing with a pre formed AVF, and only 1/8 with a CVC, in the preceeding year.

Conclusion: Our quality improvement project demonstrated an increased in adherence to a gold standard for initial access. Further analysis is required to review clinical characteristics of these patients and review any impact on cost benefit to our organisation.

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