Transcript Vascular access for haemodialysis in Scotland

Vascular access for
haemodialysis in Scotland
(Provisional)
Andrew Henderson, Keith Simpson,
Gordon Prescott, Joanne Boyd and
Alison Severn, on behalf of the Scottish
Renal Registry
Introduction
• Widely accepted that a native
arteriovenous fistula is the best form of
vascular access for haemodialysis
• Central venous lines are associated
with a higher risk of bacteraemia and
higher mortality
• Dhingra et al., 2001; Kidney Int 60:1443
• Pastan et al., 2002; Kidney Int 62:620
• Xue et al., 2003; Am J Kidney Dis 42:1013
QIS Standards
• Standard 4.4:
– A minimum of 70% of HD patients have an
arteriovenous fistula or vein graft as their
permanent access
– 2002 Peer Review
• 3 of 10 adult units reached target
– UK Renal Association Survey 4/2005
• 5 of 10 adult units reached target
• Standard 4.5:
– Permanent catheters are used as
haemodialysis access in a maximum of
20% of patients
– Met in 3 of 10 units
Questions
• How may HD patients with ERF have
fistulas, grafts, tunnelled lines etc?
• What are the determinants of access
type?
– gender, age, PRD?
• Are there large differences in access
type between units?
METHODS
Scottish Renal Registry
Audit Census Day
Ver 13
Confidential Summary and Data Collection Sheet
Graft:
17 Aug
2006
Right
Left
Radial artery to antecubital vein
Brachial artery to axillary vein
Brachial artery to brachial vein
Brachial artery to cephalic vein
Brachial artery to basilic vein
Axillary artery to axillary vein
Femoral artery to femoral vein
Popliteal artery to internal
jugular vein
Popliteal artery to femoral vein
Axillary artery to jugular vein
Femoral artery to jugular vein
Femoral artery to renal vein
AV Graft details not known
The SRR Steering Group has agreed to combine our regular audits of haemoglobin and URR with
the first survey of Vascular Access for patients using hospital or home HD for ERF.
Please complete this form for every patient who dialyses in your unit on the census day. This
includes patients who are normally registered with another unit but who are dialysing with you on
that day. It also includes all your satellites. An expanded instruction sheet has been sent to each
renal unit. A copy can be viewed on the SRR Website. Further copies of this document and the
instruction sheet are available on the SRR website http://www.show.scot.nhs.uk/SRR or you can
photocopy a blank form.
Once completed please give this form to the person responsible for entering data onto the Renal
Unit Electronic Patient Record or the Scottish Renal Registry. They will deal with data entry and
then send the form to the SRR office.
Please complete all 7 Sections of this form.
Needled but details not known Right
Needles used through the skin
but access type not known
1. Patient ID
Left
Name of Parent Renal Unit eg Monklands
Comment: Please only use this box if required to
explain a complex situation that is not covered in the
list above. In that case please add you name so that
we can contact you for further help if necessary
Location of the HD eg Home or Peterhead…
Hospital Patient ID Label would be ideal here
Patient Name : Surname
Forename
Date of Birth (dd/mm/yyyy)
_____/_____/_________
1
HD Sessions per week
Please tick the appropriate box
What is the planned Duration of this HD
session
What time will (or did) this session start
2
3
:
:
3. Today’s Pre dialysis Weight and Blood Pressure
Please record the patient’s pre dialysis weight in kg wearing
light indoor clothes without shoes.
Please record the patient’s pre dialysis sitting blood pressure
4
5
6
7
(hh:mm)
(hh:mm)
.
kg
/
mmHg
4. Vascular Access
Please tick one box which best describes the afferent (arterial) access used for HD on the Census
Day
Fistula:
Radiocephalic
Brachiocephalic
Brachiobasilic
Ulnacephalic
Radioulnar
Popliteal to long saphenous
AV Fistula details not known
Right
Left
Vein Loop
Brachial artery to brachial vein
Brachial artery to basilic vein
Femoral artery to femoral vein
Vein Loop details not known
Right
Right
Left
Tunnelled CV Catheters
(“Lines”)Line
Right
Left
Tunnelled internal jugular vein
catheter
Tunnelled subclavian vein
catheter
Tunnelled femoral vein catheter
Subcutaneous Implanted
eg “LifeSite”
Tunnelled Line details not
known
Comment
Your Name:
5. URR Audit
Please tick the box below to confirm that you have done or will do the routine April URR samples
as described in the SRR guideline on the Census Day and that you will submit the result to the
SRR in the normal way for your unit (eg via Electronic Patient Record). You do not have to enter
the results here.
URR Samples taken
6. Haemoglobin Audit
Please tick 3 boxes below to confirm that you have or will measure the following as described in
the SRR guideline on Haemoglobin Audit You do not have to enter the results here.
Haemoglobin Sample taken
Serum Ferritin Sample taken
Has the patient had a blood transfusion in the 28 days before the Hb audit sample? Yes
No
_____/_____/_________
2. HD Details
Date of HD reported for this Census
Non Tunnelled CV Catheters
(“Lines”)
Non tunnelled internal jugular
vein catheter
Non tunnelled subclavian vein
catheter
Non Tunnelled femoral vein
catheter
Non Tunnelled Line details not
known
Left
7. Haemopoietic Drugs
Please insert the prescription that is in force for the following medicines on the Census Day.
Insert “0” dose for medicines which are not prescribed. A dose or a “0” should be entered in every
box in the dose column.
Drug Name
Dose
Units
Frequency
Route
Example Epo
1000
u
3 x week
Sub cut
Example NESP
0
Example Iron
75
mg
weekly
IV
Complete Below
Epo (Alfa or Beta, aka Epoetin, Eprex NeoRecormon)
NESP (aka Arenesp, Darbepotein Alfa)
CERA
Iron Sucrose, (aka Iron Saccharate, Venofer)
Iron Dextran (aka CosmoFer)
Iron Sorbitol (aka Jectofer)
Now please ensure that this form is returned by your local coordinator as soon as possible to the
Scottish Renal Registry, Glasgow Royal Infirmary, Walton Building, Glasgow, G4 0SF
RESULTS
• 1566 patients
• Details of vascular access in 1558
patients
• 1550 prevalent patients on 5th April;
58% of these were male
• Primary renal diagnosis available for
1399 patients
Vascular access in Scotland
1200
1110
1000
Number
800
600
400
357
200
65
3
7
Vein loop
Needled NK
16
8
Non-T
Missing
0
Fistula
AVG
Access type
Tunnelled
Types of AV Fistula
600
517
500
467
Number
400
300
Series1
200
100
75
46
4
1
Radioulnar
Popliteal to long
saphenous
0
Brachiocephalic
Radiocephalic
Brachiobasilic
Details not known
Access (simplified)
AV access
Line
373
24%
76%
1185
Access by gender
100%
90%
20
30
80%
70%
60%
Line
AV
50%
40%
80
70
30%
20%
10%
0%
Female
Male
p<0.001
Access in males and females
100%
90%
80%
70%
Non-T
Tunnelled
Needled NK
Vein loop
Graft
Fistula
60%
50%
40%
30%
20%
10%
0%
Female
Male
Access and Age
100%
90%
80%
Number of patients
70%
60%
Line
AV
50%
40%
30%
20%
10%
0%
1st(oldest)
2nd
3rd
Age quartile
4th
Access by Age and Gender
100%
90%
80%
70%
60%
Non-T
Tunnelled
Needled NK
Graft
Fistula
50%
40%
30%
20%
10%
0%
Older F
Younger F
Older M
Younger M
Access and Primary Renal Disease
100%
80%
60%
Line
AV
40%
20%
0%
GN
Interstitial
Multisystem
Diabetes
Unknown
p=0.014
Access in patients with Diabetes as PRD
100%
90%
80%
70%
60%
Line
AV
50%
40%
30%
20%
10%
0%
DN
Non-DN
p=0.034
Access by Unit
100%
90%
80%
70%
60%
Line
AV access
50%
40%
30%
20%
10%
0%
Scotland
1
2
3
4
5
6
7
8
9
10
11
Unit
p<0.001
Access by Satellite Unit
100%
90%
80%
70%
60%
Line All
AV All
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
9
10
11
12
13
Scotland
Satellite Units vs Parent Unit
100%
90%
80%
70%
60%
Line All
AV All
50%
40%
30%
20%
10%
0%
Unit A Sat
Unit A
Unit B Sat
Unit B
Unit C Sat
Unit C
Unit D Sat
Unit D
Unit E Sat
Unit E
Unit F Sat
Unit F
Home Haemodialysis
90%
85%
80%
70%
60%
50%
40%
30%
20%
8%
10%
4%
0%
0%
2%
0%
Graft
Fistula
Needled NK
Tunnelled
Non Tunnelled
Missing
Conclusions
• Access is dependent on:
– Renal Unit
– Sex
– Primary Renal Disease
• The number of units reaching targets is
improving and is now 70% of adult units
Future Work
• Association with haemoglobin and
erythropoietin data.
• Association with URR and dialysis time data.
• Grant applied for to allow prospective data
collection to look more fully at vascular
access practice and impact on outcomes.