Despite the well-documented advantages of permanent access placement, 82% of patients initiating hemodialysis (HD) in the United States in 2006 did so with a catheter.
Even in patients followed by a nephrologist for at least six months, the rate of patients starting dialysis with a catheter was 75%. HD catheters are associated with the worst mortality risk by access type, and changing to a fistula, graft, or peritoneal dialysis (PD) catheter can significantly improve patient survival. In light of these findings, we discuss some important access-management strategies that health-care providers should keep in mind for patients with progressive CKD.
Timely referral and access to nephrology services remains the foundation for the optimal management of CKD. Estimated glomerular filtration rate (eGFR) should be monitored routinely in patients with advanced or progressive CKD.
Recently, the members of the American Clinical Laboratory Association (ACLA) unanimously agreed to report eGFR whenever a measurement of creatinine is reported. Based on eGFR values, we advocate a “rule of 30-20-10” mnemonic that corresponds to eGFR action thresholds in the preparation of patients for possible dialytic therapy.
When the eGFR is at or below 30 cc/min, the patient should be evaluated by a nephrologist and, if needed, followed jointly with the referring physician. Early nephrology referral has been associated with reduced morbidity, mortality, and cost.
In addition to BP, anemia, cardiovascular risk, and mineral/metabolism management, nephrologists should initiate the discussion of future access placement and dialytic therapy options (including transplantation). This discussion should take place early in the management process and include the patient, family, and primary-care physician. Patients who feel empowered and have realistic expectations of the process are less likely to resist and delay the provision of “lifesaving” care in the future.
When the eGFR falls below 20 cc/min, the patient should make an informed decision about the modality of treatment. If the choice is HD, the patient should be referred for creation of an arteriovenous fistula (AVF). If PD is selected, access placement can be delayed, depending on the rate of eGFR decline, although some advocate for AVF creation even in patients who elect for PD.
One novel approach is the provision of “informed non-consent” for patients eligible for permanent access who refuse or delay placement. Signature of “non-consent forms,” which outline the benefits and risks of catheter use and early AVF creation, may help to “inform” the vascular-access placement decision. Another reason for the delay of AVF creation is that approximately 30-50% of incident end-stage renal disease (ESRD) patients are not Medicare-eligible and may not have coverage for pre-emptive AVF placement before the initiation of chronic dialysis.
By the time the eGFR falls below 10 cc/min (or 15 cc/min in patients with diabetes), the patient should have a mature access and be ready for the initiation of chronic renal replacement therapy. While we recognize the decision to start dialysis is highly individualized, this approach would result in more patients having a mature access, either for PD or HD, at the initiation of ESRD therapy, a goal we all support.
In conclusion, the appropriate and timely provision of medical care can significantly decrease morbidity and mortality in patients preparing for possible chronic renal replacement therapy. We propose a multifactorial approach where the “rule of 30-20-10” provides critical action thresholds for timely nephrology referral (eGFR 30 cc/min or less), permanent access placement (eGFR 20 cc/min or less), and the evaluation of dialysis initiation (eGFR 10 cc/min or less).
Dr. Chan is a researcher with Fresenius Medical Care in Waltham, Mass., where Dr. Pulliam is Vice President of Medical Affairs for Home Therapy and Dr. Hakim is Senior Executive Vice President.