Global variations in funding and use of hemodialysis accesses: an international report using the ISN Global Kidney Health Atlas.

There is a lack of contemporary data describing global variations in vascular access for hemodialysis (HD). We used the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to highlight differences in funding and availability of hemodialysis accesses used for initiating HD across world regions. Survey questions were directed at understanding the funding modules for obtaining vascular access and types of accesses used to initiate dialysis. An electronic survey was sent to national and regional key stakeholders affiliated with the ISN between June and September 2022. Countries that participated in the survey were categorized based on World Bank Income Classification (low-, lower-middle, upper-middle, and high-income) and by their regional affiliation with the ISN. Data on types of vascular access were available from 160 countries. Respondents from 35 countries (22% of surveyed countries) reported that > 50% of patients started HD with an arteriovenous fistula or graft (AVF or AVG). These rates were higher in Western Europe (n = 14; 64%), North & East Asia (n = 4; 67%), and among high-income countries (n = 24; 38%). The rates of > 50% of patients starting HD with a tunneled dialysis catheter were highest in North America & Caribbean region (n = 7; 58%) and lowest in South Asia and Newly Independent States and Russia (n = 0 in both regions). Respondents from 50% (n = 9) of low-income countries reported that > 75% of patients started HD using a temporary catheter, with the highest rates in Africa (n = 30; 75%) and Latin America (n = 14; 67%). Funding for the creation of vascular access was often through public funding and free at the point of delivery in high-income countries (n = 42; 67% for AVF/AVG, n = 44; 70% for central venous catheters). In low-income countries, private and out of pocket funding was reported as being more common (n = 8; 40% for AVF/AVG, n = 5; 25% for central venous catheters). High income countries exhibit variation in the use of AVF/AVG and tunneled catheters. In low-income countries, there is a higher use of temporary dialysis catheters and private funding models for access creation.

Ghimire A ，Shah S ，Chauhan U ，Ibrahim KS ，Jindal K ，Kazancioglu R ，Luyckx VA ，MacRae JM ，Olanrewaju TO ，Quinn RR ，Ravani P ，Shah N ，Thompson S ，Tungsanga S ，Vachharanjani T ，Arruebo S ，Caskey FJ ，Damster S ，Donner JA ，Jha V ，Levin A ，Malik C ，Nangaku M ，Saad S ，Tonelli M ，Ye F ，Okpechi IG ，Bello AK ，Johnson DW ... -  《BMC Nephrology》

Global variability of vascular and peritoneal access for chronic dialysis.

Vascular and peritoneal access are essential elements for sustainability of chronic dialysis programs. Data on availability, patterns of use, funding models, and workforce for vascular and peritoneal accesses for dialysis at a global scale is limited. An electronic survey of national leaders of nephrology societies, consumer representative organizations, and policymakers was conducted from July to September 2018. Questions focused on types of accesses used to initiate dialysis, funding for services, and availability of providers for access creation. Data from 167 countries were available. In 31 countries (25% of surveyed countries), >75% of patients initiated haemodialysis (HD) with a temporary catheter. Seven countries (5% of surveyed countries) had >75% of patients initiating HD with arteriovenous fistulas or grafts. Seven countries (5% of surveyed countries) had >75% of their patients starting HD with tunnelled dialysis catheters. 57% of low-income countries (LICs) had >75% of their patients initiating HD with a temporary catheter compared to 5% of high-income countries (HICs). Shortages of surgeons to create vascular access were reported in 91% of LIC compared to 46% in HIC. Approximately 95% of participating countries in the LIC category reported shortages of surgeons for peritoneal dialysis (PD) access compared to 26% in HIC. Public funding was available for central venous catheters, fistula/graft creation, and PD catheter surgery in 57%, 54% and 54% of countries, respectively. There is a substantial variation in the availability, funding, workforce, and utilization of vascular and peritoneal access for dialysis across countries regions, with major gaps in low-income countries.

Ghimire A ，Shah S ，Okpechi IG ，Ye F ，Tungsanga S ，Vachharajani T ，Levin A ，Johnson D ，Ravani P ，Tonelli M ，Thompson S ，Jha V ，Luyckx V ，Jindal K ，Shah N ，Caskey FJ ，Kazancioglu R ，Bello AK ... -  《-》

Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD.

The optimal timing of vascular access referral for patients with chronic kidney disease who may need hemodialysis (HD) is a pressing question in nephrology. Current referral policies have not been rigorously compared with respect to costs and benefits and do not consider patient-specific factors such as age. Monte Carlo simulation model. Patients with chronic kidney disease, referred to a multidisciplinary kidney clinic in a universal health care system. Cost-effectiveness analysis, payer perspective, lifetime horizon. The following vascular access referral policies are considered: central venous catheter (CVC) only, arteriovenous fistula (AVF) or graft (AVG) referral upon HD initiation, AVF (or AVG) referral when HD is forecast to begin within 12 (or 3 for AVG) months, AVF (or AVG) referral when estimated glomerular filtration rate is <15 (or <10 for AVG) mL/min/1.73m2. Incremental cost-effectiveness ratios (ICERs, in 2014 US dollars per quality-adjusted life-year [QALY] gained). The ICER of AVF (AVG) referral within 12 (3) months of forecasted HD initiation, compared to using only a CVC, is ∼$105k/QALY ($101k/QALY) at a population level (HD costs included). Pre-HD AVF or AVG referral dominates delaying referral until HD initiation. The ICER of pre-HD referral increases with patient age. Results are most sensitive to erythropoietin costs, ongoing HD costs, and patients' utilities for HD. When ongoing HD costs are excluded from the analysis, pre-HD AVF dominates both pre-HD AVG and CVC-only policies. Literature-based estimates for HD, AVF, and AVG utilities are limited. The cost-effectiveness of vascular access referral is largely driven by the annual costs of HD, erythropoietin costs, and access-specific utilities. Further research is needed in the field of dialysis-related quality of life to inform decision making regarding vascular access referral.

Shechter SM ，Chandler T ，Skandari MR ，Zalunardo N ... -  《-》

Trends in US Vascular Access Use, Patient Preferences, and Related Practices: An Update From the US DOPPS Practice Monitor With International Comparisons.

Since the bundled end-stage renal disease prospective payment system began in 2011 in the United States, some hemodialysis practices have changed substantially, raising the question of whether vascular access practice also has changed. We describe monthly US vascular access use from August 2010 to August 2013 with international comparisons, and other aspects of US vascular access practice. Prospective observational cohort study of vascular access. Maintenance hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) in the United States (N=3,442; US patients) and 19 other nations (N=8,478). Country, patient demographics, time period. Vascular access use, pre-end-stage renal disease access timing of first nephrologist care and arteriovenous access placement, patient self-reported vascular access preferences (United States only), treatment practices as stated by medical directors. In the United States from August 2010 to August 2013, arteriovenous fistula (AVF) use increased from 63% to 68%, while catheter use declined from 19% to 15%. Although AVF use did not differ greatly across age groups, arteriovenous graft use was 2-fold higher among black (26%) versus nonblack US patients (13%) in 2013. Across 20 countries in 2013, AVF use ranged from 49% to 92%, whereas catheter use ranged from 1% to 45%. Patient-reported vascular access preferences differed by sex and race, with 16% to 20% of patients feeling uninformed regarding benefits/risks of different vascular access types. Among new (incident) US hemodialysis patients, AVF use remains low, with ∼70% initiating hemodialysis therapy with a catheter (60% starting with catheter when having ≥4 months of predialysis nephrology care). In the United States, longer typical times to first AVF cannulation were reported. Noncompletion of surveys may affect the generalizability of findings to the wider hemodialysis population. AVF use has increased, with catheter use decreasing among prevalent US hemodialysis patients since the introduction of the prospective payment system. However, AVF use at dialysis therapy initiation remains low, suggesting that reforms affecting predialysis care may be necessary to incentivize improvements in fistula rates at dialysis therapy initiation as achieved for prevalent hemodialysis patients.

Pisoni RL ，Zepel L ，Port FK ，Robinson BM ... -  《-》

Predialysis nephrology care amongst Palestinian hemodialysis patients and its impact on initial vascular access type.

Atieh AS ，Shamasneh AO ，Hamadah A ，Gharaibeh KA ... -  《-》