Debbie Brouwer-Maier Offers Her Perspective on Kidney Care Issues
As a nephrology professional who has devoted countless hours of volunteer time to support the body of work reflected in the 2006 National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines on vascular access, it is difficult to witness the “march of time” with regards to the arteriovenous fistula (AVF) as the best access for patients on dialysis.
I think the “Fistula First” name did much damage. The campaign, initiated in April 2004 as a CMS-recommended practice, was frequently misconstrued to push for an AVF as the right choice for all patients. The campaign’s intention, rather, was to consider an AVF first as part of the individualization of access selection, and then, to defer to an AVG, if and when the AVF was not a suitable option.
Yes, AVF failure-to-mature rates are unacceptably high and we still do not know the root cause. Surgeons who specialize and have a high volume of AVF cases can achieve lower failure-to-mature rates. Fistula maturation studies did not review the variation in surgical techniques, anesthesia methods or even the skill of the surgeons. Most surgeons in the United States have performed less than 10 AVF cases during their training, while, in the United Kingdom, AVF surgical training includes performing 100 cases before creating an access by oneself. Skills must be mastered to improve access outcomes.
AVG material has improved to allow for early cannulation and may be a good choice for the patients with a limited life expectancy, as it can avoid a catheter and will most likely last two years. I also recommend a lower arm loop graft so that the upper arm is preserved for a future access. This approach mirrors the new proposed 2019 KDOQI “Life Plan” – the old “Patient Plan of Care” repackaged.
Catheter care has greatly improved with new ways to decrease infection rates. A large concern is, if the revised KDOQI guidelines move to make catheter an acceptable life plan for access choice, how will we care for them in the United States? We have a larger proportion of patient care nephrology technicians staffing dialysis clinics and, in may states, what they can do is limited. It is in the nursing scope of practice, not patient care technicians, to initiate or terminate dialysis with a catheter.