Teun Wilmink 1) and Sarah Powers 2), Dept of Vascular Surgery 1) and Renal Medicine 2). Heart of England NHS Foundation Trust, Birmingham

 Trends in fistula en CVC rates in HEFT  Organisatie van de access service in HEFT ◦ Rol van de Pre-dialysis service ◦ Rol van de Access co-ordinator ◦ Hoe wij de Access chirurgie doen ◦ Post access surveillance  Lessons learnt

MDTAccess Clinic

UK Renal Registry 17th Annual Report

 Capture the patients as early as possible ◦ Find CKD stage 3 patients in the community ◦ Make GP aware of CKD in their patients  Organise their care in a separate nurse led pre-dialysis clinic

Percentage of patients presenting <90 days prior to starting RRT, 2012/2013 HEFT % UK% %

Percentage of patients presenting > one year prior to starting RRT, 2012/2013 UK Renal Registry Report %

Kennedy DM, Chatha K, Rayner HC Laboratory database population surveillance to improve detection of progressive chronic kidney disease. Journal of Renal Care 2013; 39 Suppl 2:23-9 “CKD Made Easy – a guide for general practice” Google: ‘CKD Made Easy’ Since 2012: Laboratory surveillance and selective graphical reports Clever Nephrologist

 Separate nurse led pre-dialysis clinic  eGFR < 25 ml/min AND dropping by more than 5ml/min per year ◦ Kidney failure nurse ◦ Dietician ◦ (Nephrologist)  One to one education  Medical management  Dietary advice  Anemia management

 Kidney failure nurses co-ordinate clinic  Perform initial assessment within agreed guidelines then liaise with team members as appropriate.  Ensure all patients approaching RRT are prepared psychologically, educationally and physically (holistic care)

 On average 18 months in the pre- dialysis clinic  Prolong time till dialysis  ? Increase survival of patients on dialysis  Patient has made a choice about modality

 Liaises with pre- dialysis team  Prioritises patients for access assessment  Organises the access clinics  Organises access lists  Education of dialysis nurses  First point of referral for access problems

Capture patients heading for dialysis early Timely referral Accurate assessment Good surgery Efficient Follow up

 Think about access if eGFR below 20.  Weekly access clinic run and staffed by the access coordinators.  (Mostly) 2 vascular surgeons with portable US scanners.  Patient gets operation date in clinic.  We book on all lists of 4 access surgeons depending on patient need, operation details and type list.

 Good pre-op assessment is key to success  Clinical assessment is qualitative, depends on experience and is difficult to standardise

In access clinic by the surgeon Portable ultrasound Arteries ● Diameter Duplex waveform Flow direction Veins (with tourniquet) ● Diameter Patency (follow vein up) Anatomy

 Vein  ≥ 2 mm at wrist, ≥ 3 mm at elbow  Compressible  Upstream outflow patent  Artery  ≥ 2 mm at wrist, ≥ 3 mm at elbow  Antegrade flow  Normal Doppler waveform Simple standardised criteria

Percent needledNr weeks Median

 Half of the fistulae can be needled after 8 weeks  Three quarters can be needles after 13 weeks

Log rank test p <

Log rank test p < 0.001

medianp75 Maturation time813 Wait for assessment 36 Wait for operation47 Total1526

Percentile15 to 1020 to 10 p p median1750 p p pre-dialysis patients

Timely referral  RCAVF’s have best survival  AVF survival is much better in pre- dialysis patients  75% of AVF are needled in 16 weeks  Decline in eGFR is highly individual  We refer at 16 but start thinking about access if eGFR falls below 20  We need individual prediction of estimated dialysis date

YearTotalPrimary AVFAVF revisionsAVGCAPD

 Joint working party of the UK Renal Association and the UK Vascular Society estimated:  135 procedures are needed per 100 new haemodialysis patients  30 surgical vascular access procedures per 100 prevalent haemodialysis patients per year  We should do around 260 operations per year

 We need 75 to 80 access list per year ◦ 50 local lists ◦ 30 GA lists

 See all patients within 2 weeks after access operation ◦ Dialysis patients in their dialysis units ◦ Pre-dialysis patients in access clinic  Thrill present: 95% chance AVF can be used for dialysis  No thrill: measure venous diameter ◦ if diameter > 5 mm: see in 4 weeks ◦ If diameter< 5 mm: detailed duplex scan

Log rank test p <

Log rank test p <

Wanneer prikken?  AVF survival is better if needled after 16 weeks  Six successful dialysis sessions from start most important predictor of AVF survival  Before 16 weeks, early needling is not detrimental (if you don’t muck it up)  Experienced dialysis nurse is best judge

UK Renal Registry 17th Annual Report Access for first dialysis in patients presenting to nephrologist <90 days prior to dialysis start

 Organise pre-dialysis clinic  Appoint access co-ordinator  Find enthusiastic access surgeons  Establish access clinic ◦ New patients ◦ Follow up  Organise access operation lists ◦ Local anesthetic lists ◦ General anesthetic lists  Organise post surgery follow up  Use PD for late referrals