Vivekanand Jha, Rajasekara Chakravarthi, Kamal D. Shah

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Vivekanand Jha, Rajasekara Chakravarthi, Kamal D. Shah Vascular access in dialysis patients: Observations from a national dialysis cohort in India Vivekanand Jha, Rajasekara Chakravarthi, Kamal D. Shah

Introduction EBPG on vascular access 1.2. Every CRF patient should start with functioning vascular access 1.3. Potential chronic patients should be referred for vascular access at eGFR < 30 ml/min Aim: minimization of use of catheters, with related morbidity and hospitalizations Native AVF considered the gold standard for vascular access Several initiatives have promoted an early construction of AVF in HD patients

Gallieni et al, Seminars Interven Radiol 2012

Introduction HD is growing rapidly in India Vascular access an important limiting factor for patient outcomes The pattern of vascular access in chronic HD patients in India is not known

To describe the vascular access use in a large pan-India HD cohort Aim of the study To describe the vascular access use in a large pan-India HD cohort

Methodology Multicentric retrospective observational study Study setting: NephroPlus dialysis centers (n=31) Patients who started dialysis from Jan 2013 to Dec 2014 Nature of vascular access at the time of joining the program noted Access related events monitored

Location of NephroPlus HD centers

Results Number of subjects: 1,688 Age: 52.2 ± 14.1 (15­82) yrs Sex ratio: 6.9:3.1 Cause of kidney disease: Hypertensive Nephrosclerosis 46% Diabetic Nephropathy 35%. Others 19% Time since diagnosis of ESRD: 14.4 ± 18.7 (0-198) mo Dialysis start: de novo: 21% transfer from other facilities: 79%

Vascular access at the time of entry   No of cases Percent AVF 1054 62 Non-tunnelled dialysis catheter 555 33 Tunnelled dialysis catheter 42 3 AV Shunt 19 1 AV Graft 18 Total 1688 100

Access pattern according to centers where HD was initiated   AVF Catheter Those who started HD elsewhere 64% 35% Those who started HD in NephroPlus facility 59% 38%

Access type in incident patients over time

Access pattern in different centers Jan 2013

Access pattern in different centers Dec 2014

Association between reimbursement type and time to creation of AVF Type of reimbursement Mean no. of days Pvt. Insurance 46 ± 43 (4­277) Govt. Sponsored 51 ± 42 (4­269) Self-paying 58 ± 50 (5­305) All 58 ± 49 (4­305)

Follow up Follow up period: 15.44 ± 18.5 (range 1­24) mo (14,844 patient months) A total of 64 interventions needed in 54 patients Dropouts Patients continuing on HD Dropouts AVF at start 67.2% 32.8% No AVF at start 63.6% 36.4%

Conclusions First study to describe the pattern of vascular access in India A high proportion of incident patients had AVF, and AVF use improved over study period Possible to achieve uniformity across centers with appropriate access planning Limitations Selected patient population Large proportion had been initiated on HD elsewhere before entry in NephroPlus center Details of factors influencing access choice not available