A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients (2021)

Type of publication:
Journal article

Author(s):
Jaffer, Ounali; Gibbs, Paul; Gibson, Matthew; Gilbert, James; Hanko, Jennifer; Jeevaratnam, Praveen; Jones, Robert; *Nicholas, Johann; Ramnarine, Raymond; Sivaprakasam, Rajesh; Steiner, Kate; Tippett, Richard; Wilkins, Jason

Citation:
Cardiovascular and interventional radiology; Jul 2021 [epub ahead of print]

Abstract:
PURPOSE Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus. METHODS A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice. RESULTS The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultra-high-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions. CONCLUSIONS These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying AVF stenoses and provide unified evidence-based practice guidelines.

Home haemodialysis: barriers and stepping stones (2019)

Type of publication:
Journal article

Author(s):
*Nair, Sunita; *Kanbar, Ammar; Bajo, Maria

Citation:
Journal of Kidney Care; Sep 2019; vol. 4 (no. 5); p. 240-245

Abstract:
Despite national recommendations and well-chronicled benefits for extended hours home haemodialysis, uptake remains poor. The issues surrounding this are multifactorial. There are barriers to uptake at all levels of care—patient, clinician and commissioning. This article looks at some of those barriers and addresses them.

MON-112 Home Haemodialysis (HHD) with low dialysate volume (LDV) – The green benefit (2019)

Type of publication:
Conference abstract

Author(s):
*Nair, S.; Gautier J.

Citation:
Kidney International Reports; Jul 2019; vol. 4 (no. 7), S350

Abstract:
Introduction: Man-made greenhouse gas emissions have impacted climate changes significantly. This has
adversely affected human health presently and has serious implications for future generations. Healthcare
industry itself contributes towards these carbon footprints. In England, 3.2% of the total CO2 emissions are accounted for by the healthcare industry alone producing 18 million tons CO2eq emissions. National Health Services (NHS) England CO2 emissions exceeds the total emissions from all aircraft departing from Heathrow, the largest European airport. Dialysis patient care accounts for 62.5% of the carbon footprint of a renal service. In UK, the prevalence rate of dialysis patients is 440 patients per million population, that is 25,261 haemodialysis (HD) patients in 2016. 1256 patients received dialysis at home. In-centre HD undertaking dialysis 4 hours 3 times/week, consumes more than 55,000 Litres of water/patient/year and contributes 3,818 kgCO2eq to the carbon footprint. A LDV system may have less emissions compared to traditional machines.
Method(s): This footprint is influenced more by frequency of treatments rather than duration. On average in Europe, patients using NxStage System One (NSO) dialyse 5.7 times for 2.6 hours/week with 24.3 Litres of dialysate/session to deliver a 2.61 stdKt/V. Based on manufacturers data, we calculated fluids volume, weight and energy required with NSO and we compared with requirements to deliver 3 times/week HD or the same clearance with traditional machines (3.5 times/week to deliver a 2.6 stdKt/V in the same patient).
Result(s): Reduced water usage NSO with PureFlow allows to prepare dialysate in-situ. It includes deionization technology and converts 1 Litre source water to 1 Litre of ultrapure dialysate as against traditional osmosis water systems which have a conversion rate of around 50%. Frequent therapy as above utilizes 7377 Litres of source water/year, only 13% of the 56,160 Litres of water used in centre HD and 12% of the 59,717 Litres of water required to deliver the same clearance with a traditional system. Low shipping volume of dialysate concentrates Fluids is the main contributor to shipping volumes in dialysis supplies. PureFlow system allows a minimal shipping volume of 422 Litres of concentrate including buffer per patient-year vs. 702-780 Litres of acid concentrate (dilution 1/43 or 1/35) in conventional HD or 819-910 Liters to deliver the same clearance as with NSO. PureFlow concentrate equals 1.5ton and 0.8m3 per patient-year. Conventional therapy equals 0.9-1.1 ton and 1.4-1.7 m3 (dilution 1/43 or 1/35) of acid concentrate. Delivering the same clearance with a traditional system equals 1.0-1.2 ton and 1.6-2.0 m3. Less energy consumption NSO with PureFlow utilizes 8.2-10.7 kwh to deliver 6 sessions/week. This is 28% less than 29.6-52.9 kwh to deliver 3 sessions/week with a traditional system. If one includes the energy used for water treatment which amounts to 32.5-63.2 kwh/week without heat disinfection, PureFlow usage is less than 20% of this.
Conclusion(s): Despite increased frequency, HHD with LDV is a much greener option for dialysis patients and significantly reduces the carbon footprint. Such systems are the order of the day where one is constantly looking for effective greener options in delivering treatments for our patients.

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