Implementation of a predialysis pathway to increase arteriovenous fistula use at the commencement of haemodialysis: The KHA-CARI vascular access implementation project

Abstract

Aim: To increase utilization of arteriovenous fistulae (AVF) at haemodialysis commencement via implementation of a predialysis pathway. Background: Patients who commence haemodialysis with a AVF have lower morbidity and mortality. AVF use at the first dialysis remains unacceptably low in Australasia. Methods: A multicentre, before-after study was conducted over 18 months. Interventions included implementation of a formalized pre-dialysis pathway, with emphasis on pre-dialysis patient education, and encouraging specific eGFR thresholds for vascular access (VA) referral (eGFR 20 ml/min) and placement (eGFR 15 ml/min). Logistic regression was used to assess the effect of the intervention on catheter use at commencement of haemodialysis. Results: Nine nephrology centres commenced 1013 patients during the study, 323 in the baseline phase and 690 during the intervention phase. The proportion of patients receiving predialysis education was unchanged following the intervention phase (65% vs 64%, p = 0.83). eGFR at surgical review and VA placement rose significantly (8.5 vs 10.6 & 8.1 vs 10.6 ml/min respectively, p < 0.001) but remained lower than predialysis pathway thresholds. The proportions commencing with an AVF pre and post intervention were unchanged (40 vs 41%, p = 0.86), with no change following adjustment for age, gender, late referral, centre & pre-dialysis education (OR 0.92, p = 0.58). Three of 9 centres demonstrated increases in AVF use of 11, 15 & 20%, while 3 centres reduced AVF use between 3 and 9%. No interaction was seen between treating centre and the intervention phase (all P > 0.05). Conclusions: Implementation of a predialysis pathway did not increase AVF use at first dialysis but was associated with higher eGFR at access placement. Longer and multifaceted interventions are more likely to be effective in increasing AVF usage at first dialysis.<br />