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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 6  |  Page : 1217-1224
Causes of the delay in creating permanent vascular access in hemodialysis patients

1 College of Medicine, King Saud Bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
2 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
3 Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

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Date of Web Publication29-Jan-2021


Majority of the chronic kidney disease (CKD) patients undergo hemodialysis (HD) with central venous catheter which has multiple complications. This study aims to identify the physicians’ perspectives regarding the reasons of delayed arteriovenous fistula (AVF) creation in the Kingdom of Saudi Arabia to improve the quality of CKD patients’ care and prognosis and prevent complications. A cross-sectional descriptive study was conducted on KSA nephrologists using a questionnaire which includes factors associated with delay in AVF creation, which were categorized into patient, physician, and hospital factors. The optimal timing of starting dialysis was also assessed. In a total of 212 participants, 131 (61.8%) were of consultant level, with the largest numbers being from the Central region (52.4%). The most important patient factors associated with delay in AVF creation were denial of kidney disease or the need of AVF (76.4%), dialysis fears and practical concern (75.9%), and patient refusal (73.1%). The most important physician and hospital factors were insufficient conduction of predialysis care and education (63.7%) and late referral to a nephrologist (56.6%). Participants would create AVF when the patient reaches Stage 4 CKD (69.3%) or Stage 5 (27.4%), and 88.7% of the participants would do so 3–6 months before the anticipated start of HD. Over two-thirds of the participants (68.4%) chose patient as the main factor contributing to the delay of permanent vascular access. A validated approach to patient selection, patient-centered predialysis care, and referral to vascular access creation that could be applied on different types of patients in different regions is required.

How to cite this article:
Alfarhan MA, Almatrafi SA, Alqaseer SM, Albkiry YA, AlSayyari A. Causes of the delay in creating permanent vascular access in hemodialysis patients. Saudi J Kidney Dis Transpl 2020;31:1217-24

How to cite this URL:
Alfarhan MA, Almatrafi SA, Alqaseer SM, Albkiry YA, AlSayyari A. Causes of the delay in creating permanent vascular access in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Oct 18];31:1217-24. Available from: https://www.sjkdt.org/text.asp?2020/31/6/1217/308330

   Introduction Top

Chronic kidney disease (CKD) is a massive public health issue which has a large effect on morbidity and mortality worldwide. Hemo-dialysis (HD) is one of the main forms of renal replacement therapy (RRT) for end-stage renal disease (ESRD). An arteriovenous fistula (AVF) is the preferred access for chronic HD as it is the least to be associated with complications.[1] Although the use of AVF is recommended by guidelines of multiple countries globally, the majority of patients undergo HD with a central venous catheter (CVC) which has multiple complications.[2] It is well known that starting the dialysis with CVC is linked to a high rate of mortality and morbidity.[3],[4] Prolonged CVC use increases the risk of infections such as bacteremia and septicemia, which is related to the high risk of myocardial infarction, stroke, peripheral vascular disease, and eventually death.[5],[6] In addition, the financial cost of CVC use is higher compared to the use of fistulae and grafts.[7]

The prevalence of the use of CVC is increasing over the past few years in the Kingdom of Saudi Arabia. Among 16,315 patients undergoing HD in the KSA in 2016, 61% of those patients were using AVF as vascular access, 26% were using CVC, and 5% were using an arteriovenous graft (AVG). The prevalence of CVC rose to 30% in 2017.[8]

Possible reasons for delayed or un-creation of AVF may be related to patient, physician, or hospital factors. Patient factors include fear of pain, concern about body image, interference with lifestyle, or patient refusal.[9] Factors related to nephrologists include long waiting time to see a nephrologist, failure to refer the patient to a vascular surgeon, and insufficient predialysis education.[7],[10]

Hospital factors include lack of pre-ESRD clinics, prolonged waiting time in the process from seeing a nephrologist until the creation of an AVF, or unable to undergo surgery due to lack of insurance.[2],[7],[9] In clinical practice, physicians’ knowledge and perception can influence the time for creation of AVF and initiation of HD.

This study aims to evaluate the causes of the delay in creating AVF, by identifying the physicians’ perspectives regarding the reasons of delayed AVF creation in ESRD patients. In addition, it explores the current practice of nephrologists in the KSA regarding the optimal time to refer patients for vascular access initiation.

   Methodology Top

This is a cross-sectional descriptive study using questionnaires to collect data from nephrologists currently working in the KSA, covering 66 centers. The responses by the participants were compared for “consultant-” level physicians versus “below consultant-” level physicians, male versus female, and the regions within the KSA.

Sample size was estimated using the 95% confidence interval, 5% significance level, and a population of 529 participants. The optimal required sample size was 223 participants. The response rate was 41.6%. All the active adult nephrology physicians in the Saudi Council for Health Specialties register were contacted.

Data were collected using an online survey. The survey was distributed from May 23, 2020, and closed on July 19, 2020, using online forms (available as supplemental online material) via Google Forms through emails, text, and WhatsApp. If no response was received, the participants were sent two reminders on different occasions over a two-week period. All questions in the survey were mandatory and the survey can be submitted without completing all the questions. The survey was validated by nephrology consultants and was piloted on ten physicians working at HD centers. Their response demonstrated good understanding of the survey content without need for further modifications. The survey was developed and pretested in English.

The survey questions were aimed at discovering the physicians’ opinions and perception about the reasons for the delay in the creation of permanent vascular access in CKD patients. It included questions on demographics of the participants; factors associated with delay in AVF creation categorized into patient, physician, and hospital factors; nephrologists’ views about the optimal timing of dialysis initiation; patient education about RRT; and finally the perceived hurdles in referrals for vascular access creation.

The study was approved by the Institutional Review Board of King Abdullah International Medical Research Centre. Informed consent was obtained from all participants before starting the survey. The survey was self-administered and did not have any identifying information. The participants’ confidentiality was maintained by limiting the access to this sheet to the principal and co-investigators.

The collected data were entered into an excel file. The IBM SPSS Statistics for Windows version 23.0 (IBM Corp., Armonk, NY, USA) was used for all statistical analyses. P <0.05 was considered statistically significant. Data were presented as mean and standard deviation for continuous variables (such as age) and frequency and percentages for categorical variables (such as gender and profession). Patient, physician, and hospital factors associated with delay in AVF creation score were created by summing up the responses to ten Likert-scale questions, ranging from “1: agree” to “3: disagree.” A limiting factor leading to delayed vascular access score was created by summing up the responses to 10 Likert-scale questions, ranging from “1: very important” to “4: least important.”

   Results Top

Of the total 212 participants, 131 (61.8%) were of consultant status. The mean age was 48.7 ± 10 years and 84.9% were male. All the five regions in the KSA were represented in the survey, with the largest numbers being from the Central region (52.4%) and Western region (23.6%) [Table 1].
Table 1: Characteristics of the study sample.

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[Table 2] demonstrates the patient factors associated with delay in AVF creation in descending order. The three most important factors were thought to be “denial of kidney disease or the need of AVF” (76.4%), “dialysis fears and practical concern” (75.9%), and “patient refusing to undergo AVF surgery” (73.1%). The three least important factors were thought to be “mistrust (poor doctor–patient relationship)” (35.5%), “fast unexpected deterioration of patient kidney function,” (20.3%) and “changed decision after the creation of a fistula” (18.9%). The responses regarding the patient factors were not affected when comparing the responses from the Central and Western regions. However, significantly fewer consultants (42.7%) than below consultants (45.7%) pointed out that “patient noncompliance with nephrology appointments” was a statistically significant factor (P = 0.046).
Table 2: Patient factors associated with delay in AVF creation.

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[Table 3] shows the physician and hospital factors associated with delay in AVF creation in descending order. The most important factor was thought to be “insufficient conduction of pre-dialysis care and education about AVF initiation to the patient” (63.7%) and the least important factor was thought to be “prolonged waiting time to see a nephrologist after referral (24.1%).
Table 3: Physician and hospital factors associated with delay in arteriovenous fistula creation.

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The responses regarding the physician and hospital factors were similar among the consultant and the below consultant groups except in the “late referral to a nephrologist” factor to which significantly more consultants agreed (65.6% vs. 42.0%) (P = 0.003). On the other hand, when comparing the Central and Western regions, we found significant differences in two physician and hospital factors, with higher agreement seen in the Central region responders. These two factors are “prolonged waiting time to see a nephrologist after referral” (33.3% vs. 14%, respectively) (P = 0.007) and “lack of formal policies for when to refer a patient for surgical review and access creation” (47.7% vs. 32%, respectively) (P = 0.02).

Regarding the proper timing of creating a permanent access and when to refer a patient to vascular surgeons, of the respondents, 69.3% and 27.4% would create an AVF when the patient reaches Stage 4 and Stage 5 CKD, respectively, and 88.7% would do so three to six months before the anticipated start of HD. When asked how often do you experience difficulties when deciding to refer a patient to a surgeon to establish AVF, 35.0% of the participants answered often and 20.0% answered always, while 10.9% and 5.5% of them answered rarely and never, respectively. When the participants were asked if they are following a guideline regarding referral and patient care, 69.3% responded that they are following guidelines regarding referral and care of patients with CKD with the two most widely used guidelines such as Kidney Disease Improving Global Outcome (KDIGO) by 43.1% and Kidney Disease Outcomes Quality Initiative (KDOKI) by 25.7%. Over half of the respondents (53.7%) said that they have trouble when referring patients to surgeons to establish AVF: 29.7% said that this happened sometimes and 16.5% said that this happened rarely or never. The vast majority of respondents (96.7%) agree that using CVC as a vascular access has higher mortality than that of AVF and AVG.

The respondents were asked to choose one of the four possible factors that they felt was the main factor in delaying AVF creation. Over two-thirds (68.4%) chose the patient factor as the main factor [Table 4]. There was no statistically significant difference in this response irrespective of whether the respondents were consultants or below consultants (P = 0.8), but statistically significantly more respondents from the Western region choose this factor (84%) than those from the Central region (53.2%) (P = 0.002).
Table 4: The most limiting factors leading to delayed vascular access.

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   Discussion Top

The late creation of AVF in CKD patients is linked to patient, physician, and hospital factors.[7],[11] However, nephrologists’ perception is a key driver for managing this issue. This study included a wide range of nephrology care providers ranging from junior to senior, with the majority being at consultant level. The largest numbers of respondents were from the Central region and Western region. This reflects the higher number of patients on HD and HD doctors in these two regions. Initiating the dialysis with CVC is increasingly being a great cause of morbidity and mortality to CKD patients. This is also what almost all nephro-logists in this study have agreed on.

Over two-thirds of the participants chose patient factor as the major barrier for vascular access initiation. In 2010, a study was conducted to assess CKD patients’ attitude regarding AVF. The patients were interviewed and found to be suffering from a wide spectrum of symptoms, comorbidities, frustration with their disease, and altered quality of life from their dialysis; all these in turn affected their decision-making and health outcomes regarding choosing the modality of dialysis and creating AVF.[12]

In our study, the most significant patient-related factor was thought to be the denial of the need for dialysis. A study from Canada described multiple levels of patient behavior toward access creation, which included three levels, namely (a) denial of the disease and avoidance to discuss the management, (b) wait and see to take decision, and (c) active intention and acceptance. Patients categorized in the denial and avoi-dance level usually do not want to know any information about the dialysis. In addition, the fact that some patients have an asymptomatic phase makes them less likely to accept the need for a future dialysis.[10]

The second important patient factor is the fear of dialysis and practical concern. Initiating dialysis is associated with major lifelong lifestyle changes, frequent visits to the hospital, and the difficulties accessing dialysis centers.[13] Moreover, the fear of being a burden to their families adds to the patient’s concerns. It was found that treatment cost and work-related absenteeism will affect not only the patients but also their families.[10] In addition, misunderstood concepts about the effectiveness of HD add to the reluctance to accept dialysis.[14]

The third common patient factor in our study is the patient’s refusal to undergo AVF surgery. A study done in Canada demonstrated that patient’s refusal was one of the most common factors in delayed AVF creation.[12] This could be due to the poor or absent pre-dialysis education, lack of symptoms, or patients’ fear of dialysis. Thus, addressing the psychological aspect of the patients during the predialysis session and identifying the knowledge gaps in CKD patients are crucial to ease the decision-making of using the timely suitable route of dialysis for each patient.[10]

Insufficient predialysis care education about AVF to the patient has been the most agreed physician- and hospital-related barrier according to the present study. In standard of care, CKD patients in Stage 4 and above should receive appropriate educational sessions regarding their disease progression and different modality of management. These educational sessions are important to ensure patient preparation for the next step in their disease and RRT.[15] However, in the KSA, the predialysis education is still not optimal as a study conducted in the KSA in 2016 to assess the outcome of educational intervention of nephrologists regarding predialysis care showed that 61% of the participants had not attended any dialysis educational activity (e.g., lecture, course, or workshop) for more than a year.[7] Furthermore, in a survey conducted on Canadian and American nephrologists, American nephrologists agreed that patient education and access to CKD clinics is a barrier to AVF creation, whereas Canadian nephrologists disagreed with this statement as in Canada there are integrated CKD clinics with access to multidisciplinary teams. However, Canadian nephrologists think that patients’ refusal and delay in deciding which type of dialysis are major reasons for AVF creation delay despite the predialysis education they received.[12] This emphasized the need of improving the quality of predialysis education by addressing patients’ concerns, answering their questions, and using tools suiting different levels of education, all making a significant part of predialysis education.[10]

It is well known from the literature that earlier and more frequent nephrology visits are associated with increased use of AVF and improved survival rate.[12],[16] CKD patients who were followed by a nephrologist with insufficient duration of <2 months were more likely to start HD with CVC.[17],[18] Similarly, early referral is also needed to provide adequate time for the preparation and maturation of the vascular access because prolonged waiting time for surgical assessment is an important cause in delayed vascular access creation as well. The preparation involves detailed assessment of the patient with physical examination and vascular mapping. After creation, an AVF requires a minimum of six weeks to mature and be ready for use.[19] A study evaluating the reasons for late referral to vascular access for HD acknowledged the late referral to nephrologist as an important reason.[17] Therefore, timely referral to a nephrologist for evaluation and access creation is recommended at least six months prior to the anticipated need of dialysis.[20] Predicting the need for dialysis can be different from patient to patient and difficult to predict, however combining clinical judgment and calculating Kidney Failure Risk Equation can be used to aid in timely patient referral.[20],[21] We need to evaluate the primary health practice and set clear guidelines to clarify the need of urgent referral of CKD patients to nephrologist evaluation within sufficient time.

In our study when comparing between the responses of the consultant and the below consultant groups regarding the physician and hospital factors, almost all were similar except the factor of late referral to a nephrologist in which more consultants significantly agreed. The discrepancy in their responses regarding this point could be attributed to the difference in cumulative years of practice and the number of patients seen by consultants per year.

When comparing between participants from the Central and the Western regions, the participants from the Central region significantly agreed that prolonged waiting time to see a nephrologist after referral is an important barrier to early creation of AVF in comparison with Western region nephrologists. This could be due to the high number of patients seen in the Central region and more CKD patients in relation to nephrology health-care providers.

Our result showed a significant difference in the responses of Central and Western physicians regarding lack of formal policies for when to refer a patient for surgical review and access creation factor. Central region respondents agreed with this point more commonly than the Western region respondents. This factor came as the middle factor leading to delayed AVF creation, with half of the respondents agreed and half disagreed on. Currently, there are various guidelines regarding the referral of CKD patients to AVF creation; this variability could explain the difference of physicians’ opinion regarding this point.

The majority of respondents answered “yes” to the question “Is there any guideline you are following regarding referral and care of patients with CKD?” However, there was a wide range of different guidelines that were mentioned in the answers including KDIGO, KDOKI, and multiple different national policies. In addition, many respondents significantly expressed that they have a difficulty in deciding when to make the decision of referral to the surgeons to establish AVF. Regardless of the guidelines they are following, the answers suggest that the proper timing for referral to vascular access is still a challenge to nephrology physicians. It’s worth mentioning that this difficulty is also described in the literature in one study conducted in a population of patients who are mostly elderly which was explained by the multiple comorbidities that elderly have and the special need for each patient.[22] The participants of our study were adult nephrologists who might have the same issue as the study mentioned above. Thus, more studies are needed to be done to address this issue.[17],[22]

The current study has many strengths; it is the first study to explore physicians’ perspective in the KSA who are an influential factor in this problem. The study included physicians from 66 centers throughout all regions in the KSA, providing more generalized results. Moreover, the vast majority of responders are of consultant level who are more experienced in CKD patient care, which may reflect more accurate data. The data of the study were collected online in which all questions are mandatory to be answered, which prevents missing data in the questionnaire. This study has few limitations to be mentioned. It focuses on physicians’ perspective regarding the causes of delayed vascular access without including other contributing parties such as patients or vascular surgeons. Although approaching participants via an online method was more convenient, a number of participants could not be reached due to wrong contact information.

   Conclusion Top

The most agreed-on factors associated with AVF creation delay are the denial of the need for dialysis, fear of dialysis and practical concern, insufficient conduction of predialysis care and education about AVF initiation to the patient, and late referral to a nephrologist. A validated approach to patients’ selection and referral to vascular access creation that could be applied on different types of patient in different regions is required. Our study suggests that there is a need for patient-centered predialysis care regarding RRT, education, types, and shared decision-making process.

Conflict of interest: None declared.

   References Top

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Tang TT, Levin ML, Ahya SN, Boobes K, Hasan MH. Initiation of maintenance hemo-dialysis through central venous catheters: Study of patients’ perceptions based on a structured questionnaire. BMC Nephrol 2019; 20:270.  Back to cited text no. 2
Wasse H. Catheter-related mortality among ESRD patients. Semin Dial 2008;21:547-9.  Back to cited text no. 3
do Sameiro-Faria M, Ribeiro S, Costa E, et al. Risk factors for mortality in hemodialysis patients: Two-year follow-up study. Dis Markers 2013;35:791-8.  Back to cited text no. 4
Powe NR, Jaar B, Furth SL, Hermann J, Briggs W. Septicemia in dialysis patients: Incidence, risk factors, and prognosis. Kidney Int 1999;55:1081-90.  Back to cited text no. 5
Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 2001;60:1443-51.  Back to cited text no. 6
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Saudi Center for Organ Transplantation; 2020. Available from: http://www.scot.gov.sa/. [Last accessed date 9 August 2020].  Back to cited text no. 8
Goel N, Kwon C, Zachariah TP, et al. Vascular access placement in patients with chronic kidney disease Stages 4 and 5 attending an inner city nephrology clinic: A cohort study and survey of providers. BMC Nephrol 2017; 18:28.  Back to cited text no. 9
Griva K, Seow PS, Seow TY, Goh ZS, Choo JC, Foo M, et al. Patient-related barriers to timely dialysis access preparation: A qualitative study of the perspectives of patients, family members, and health care providers. Kidney Med 2020;2:29-41.  Back to cited text no. 10
Wauters JP, Lameire N, Davison A, Ritz E. Why patients with progressing kidney disease are referred late to the nephrologist: On causes and proposals for improvement. Nephrol Dial Transplant 2005;20:490-6.  Back to cited text no. 11
Xi W, MacNab J, Lok CE, et al. Who should be referred for a fistula? A survey of nephrologists. Nephrol Dial Transplant 2010;25: 2644-51.  Back to cited text no. 12
Shafi ST, Saleem M, Anjum R, Abdullah W, Shafi T. Refusal of hemodialysis by hospitalized chronic kidney disease patients in Pakistan. Saudi J Kidney Dis Transpl 2018;29: 401-8.  Back to cited text no. 13
[PUBMED]  [Full text]  
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Kim DH, Kim M, Kim H, et al. Early referral to a nephrologist improved patient survival: Prospective cohort study for end-stage renal disease in Korea. PLoS One 2013;8:e55323.  Back to cited text no. 16
Kim SM, Han A, Ahn S, et al. Timing of referral for vascular access for hemodialysis: Analysis of the current status and the barriers to timely referral. J Vasc Access 2019;20:659-65.  Back to cited text no. 17
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Tangri N, Grams ME, Levey AS, et al. Multinational assessment of accuracy of equations for predicting risk of kidney failure: A meta-analysis. JAMA 2016;315:164-74.  Back to cited text no. 21
Moist LM, Lok CE, Vachharajani TJ, Xi W, AlJaishi A, Polkinghorne KR, et al. Optimal hemodialysis vascular access in the elderly patient. Semin Dial 2012;25:640-8.  Back to cited text no. 22

Correspondence Address:
Maha A Alfarhan
College of Medicine, King Saud bin Abdulaziz University for Health Science, Riyadh
Saudi Arabia
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DOI: 10.4103/1319-2442.308330

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