Saving Veins, Saving Lives, for Patients With Chronic Kidney Disease

Abstract

Vascular access has long been recognized as the Achilles heel of the management of patients receiving maintenance hemodialysis. Such patients require cannulation with 15-gauge needles 3 times weekly, blood flows of about 400 mL/min, and treatments of 4 to 5 hours per session. This requires creation of arteriovenous fistulae using native veins or arteriovenous grafts using synthetic vein material. Absent usable vessels or time to surgically create and allow maturation of internal access for dialysis, clinicians use large-bore, dual-lumen, tunneled, cuffed dialysis catheters placed in the internal jugular vein. Robust data show that mortality among patients receiving dialysis with catheters is about 1.6 to 2.5 times higher than among those with internal access and no catheter. The higher rate of catheter use in U.S. hemodialysis patients likely explains the observed higher mortality compared with that in other countries (1, 2). These data, developed over the past 15 to 20 years, have formed the basis of consensus guidelines for better preparation of patients with chronic kidney disease (CKD) for dialysis. They have also spurred the Fistula First, Catheter Last and Fistula First Breakthrough Initiative campaigns, which are sponsored by the Centers for Medicare & Medicaid Services and designed to dramatically reduce catheter use and increase the prevalence of native vein fistulae. As parts of the National Vascular Access Improvement Initiative, they include 13 change concepts addressing many facets of planning and optimal management for patients with CKD. Although these campaigns have led to substantial improvement in the use of native vein fistulae among prevalent hemodialysis patients, national rates of catheter use by incident hemodialysis patients have hardly changed. The most recent report from the United States Renal Data System (3) still shows about 80% of incident dialysis patients using catheters for vascular access. Paje and colleagues (4) present data on the frequency of and characteristics associated with use of peripherally inserted central catheters (PICCs) in a large sample of hospitalized patients in Michigan, with attention to the presence of CKD. Of about 20500 PICCs placed in 52 hospitals during November 2013 through September 2016, 23% were in patients with stage 3b or worse CKD. Of PICCs placed in patients with stage 3b or worse CKD, 14% were placed in those receiving hemodialysis. Paje and colleagues discuss why this is important: PICCs damage veins needed for vascular access for dialysis, they reduce success rates for creation of preferred vascular access types, guidelines recommend avoiding PICCs in patients with stage 3b and worse CKD, and rates of complications are high. These important data reaffirm prior observations that too little attention has been given to vein protection guidelines for patients with CKD. Maps of incident access by state show that Michigan s catheter rate is high (3); if we had a national registry, we might be able to compare PICC avoidance practices between states like Michigan and those with lower rates. The study by Paje and colleagues is extraordinary, with so many case records reviewed by trained data abstractors. Some states have had superior vascular access performance for decades, and this regional variation suggests that variations in practice patterns drive outcomes. Because we rely mostly on observational studies for data on which to base guidelines, the practices of regions with the best outcomes are appropriate models (5, 6). Attention to vein protection guidelines is an important aspect of advanced planning for dialysis, and its neglect likely contributes to the high rate of catheterization in incident dialysis patients. Why has progress stalled? Nurses admitting patients to hospitals used to identify those with CKD who needed vein protection. In the 1980s, we doubled the patient loads of most U.S. hospital nurses, and engagement with this issue decreased thereafter. Nephrology guidelines suggest the importance of education and preparation for future renal replacement therapy for patients with CKD, yet trends in practice have been toward less time for education, even of complex patients with CKD. Shared decision making is encouraged in guidelines, but time and support staff to engage with patients and to think about patient care problems are vanishing luxuries (7). In the past, Networks (regional quality agencies for end-stage renal disease care) shared data on incident dialysis accesses with nephrology practice groups, providing important tools for quality improvement. After 2011, the Centers for Medicare & Medicaid Services stopped permitting release of this information. Access to these data should be restored. Vascular access coordinators using vascular access databases to track management of patients with CKD in various stages help communities improve outcomes. These proprietary products seem to be used less frequently in this age of tight budgets and myopic planning. The Centers for Medicare & Medicaid Services could develop and support such software and make it available in the public domainperhaps with incentives for active use. Earlier referral to nephrology of patients at risk for CKD progression results in less incident catheter use. Yet many are still referred late or become crash starts to dialysis. Risk stratification tools could help select those who need referral (8). Vein protection strategies should include not only PICC avoidance in patients with CKDin whom short-tunneled internal jugular catheters are an alternative (9)but also use of smaller-volume blood drawing. We could and should use pediatric tubes for phlebotomy for everyone. Idle intravenous catheters should be avoided (6). Electronic medical records should include tools for identifying patients who need vein-saving techniquemeaning use of the dorsa of hands for blood drawing and intravenous access whenever possibleto protect arm veins for future hemodialysis access. Blue bracelets (blue for veins) marked SAVE ARM VEINS remind patients and staff to use vein-saving technique. As individuals and as a community of professionals, we have a responsibility to our current patients with CKD to implement these recognized best practices (10). Arm vein protection, shared decision making, early education, PICC avoidance, earlier nephrology referral, better use of tools to track planning for patients with CKD, and prompt access to vascular surgical care can decrease catheter use by incident hemodialysis patients and alleviate the burdens of morbidity and mortality for this vulnerable population. As Paje and colleagues data remind us, so much of vein protection depends on decision making by nonnephrologists caring for complex patients with CKD. Hence, education and engagement of the general medical community are critically important to further progress.