Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.
Am J Kidney Dis. 2011 Jun;57(6):873-82. doi: 10.1053/j.ajkd.2010.12.020. Epub 2011 Mar 15.
Current clinical practice guidelines recommend a native arteriovenous fistula (AVF) as the vascular access of first choice. Despite this, most patients in western countries start hemodialysis therapy using a catheter. Little is known regarding specific physician and system characteristics that may be responsible for delays in permanent access creation.
Multicenter cohort study using mixed methods; qualitative and quantitative analysis.
SETTING & PARTICIPANTS: 9 nephrology centers in Australia and New Zealand, including 319 adult incident hemodialysis patients.
Identification of barriers and enablers to AVF placement.
Type of vascular access used at the start of hemodialysis therapy.
Prospective data collection included data concerning predialysis education, interviews of center staff, referral times, and estimated glomerular filtration rate (eGFR) at AVF creation and dialysis therapy start.
319 patients started hemodialysis therapy during the 6-month period, 39% with an AVF and 59% with a catheter. Perceived barriers to access creation included lack of formal policies for patient referral, long wait times for surgical review and access placement, and lack of a patient database for management purposes. eGFR thresholds at referral for and creation of vascular accesses were considerably lower than appreciated (in both cases, median eGFR of 7 mL/min/1.73 m(2)), with median wait times for access creation of only 3.7 weeks. First assessment by a nephrologist less than 12 months before dialysis therapy start was an independent predictor of catheter use (OR, 8.71; P < 0.001). Characteristics of the best performing centers included the presence of a formalized predialysis pathway with a centralized patient database and low nephrologist and surgeon to patient ratios.
A limited number of patient-based barriers was assessed. Cross-sectional data only.
A formalized predialysis pathway including patient education and eGFR thresholds for access placement is associated with improved permanent vascular access placement.
目前的临床实践指南建议将原生动静脉瘘（AVF）作为首选的血管通路。尽管如此，大多数西方国家的患者在开始血液透析治疗时使用导管。对于可能导致永久性血管通路建立延迟的具体医生和系统特征知之甚少。
使用混合方法的多中心队列研究；定性和定量分析。
澳大利亚和新西兰的 9 个肾病中心，包括 319 名成年首发血液透析患者。
识别 AVF 放置的障碍和促进因素。
开始血液透析治疗时使用的血管通路类型。
前瞻性数据收集包括有关透析前教育的数据、中心工作人员的访谈、转介时间以及 AVF 建立和透析治疗开始时的估计肾小球滤过率（eGFR）。
在 6 个月期间，有 319 名患者开始血液透析治疗，其中 39%使用 AVF，59%使用导管。血管通路建立的感知障碍包括缺乏患者转介的正式政策、手术审查和通路放置的等待时间长，以及缺乏用于管理目的的患者数据库。血管通路转介和建立的 eGFR 阈值远低于预期（在两种情况下，中位数 eGFR 均为 7 mL/min/1.73 m(2)），血管通路建立的中位等待时间仅为 3.7 周。在开始透析治疗前不到 12 个月首次接受肾病医生评估是使用导管的独立预测因素（OR，8.71；P < 0.001）。表现最好的中心的特征包括存在规范化的透析前途径，包括集中的患者数据库以及较低的肾病医生和外科医生与患者的比例。
评估的患者相关障碍数量有限。仅为横断面数据。
包括患者教育和通路放置 eGFR 阈值的规范化透析前途径与改善永久性血管通路建立相关。
