When you ask most Chronic Kidney Disease patients who conduct Dialysis what the "Gold Standard" or best method of Treatment is, they would kindly reply with the term Arteriovenous (AV) Fistula. However, for most initiating Dialysis and even long term Hemodialysis patients, "The best method (an Arteriovenous Fistula) is not always the first resort," said Dr. Mahmoud Malas (Associate Professor of Surgery at the Johns Hopkins School of Medicine).
In his co-authored study Dr. Malas noted that shockingly, of the 100,000 patients who initiate Dialysis every year, only 20% of new Dialysis patients are using AV Fistulas. Researchers said, "that means 80,000 patients aren't receiving the preferred standard of care, putting them at a higher risk of infection, blood clots and even death." While the numbers get better with time on Dialysis, what is still surprising to many Chronic Kidney Disease patients is that of the 400,000 Hemodialysis patients in the United States "approximately 25% are Dialyzing with catheters, according to estimates."
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Why would so many patients take the high risk of mortality associated with Dialysis and catheter use? Well, the answer is multilayered. Likely foremost is the fact that low income patients, patients with Chronic Kidney Disease who live in very rural areas, and even individuals who are "too busy" to visit their doctor have limited access to Hospitals and brief interaction with Primary Care Physicians, and are therefore less likely to detect early stages of kidney decline. As a result they "crash into Dialysis" where they have to start Dialysis immediately after being admitted to the hospital with life threatening symptoms. In this case a catheter must be placed as an AV Fistula would take far too long to mature (6 to 8 weeks) before use.
Once the Dialysis patient has the catheter placed, s/he may be "resistant to undergoing another surgery and want to stick to the method they already have." Hence, while a patient is expected to transition from a catheter to a AV Fistula within 90 days, it seldom happens due to patient desires, surgeon scheduling conflicts, and mandatory insurance approvals. However, the bottom line is, "“It's both surprising and disappointing,” Malas continued, "It makes me think there's something wrong with the system."
What is not surprising about this study is the direct connection it appears Researchers draw between low rates of AV Fistulas and high rates of mortality. For instance, it was noted that Fistula rates were highest in New England (Network 1) and among the lowest in Texas (Network 14). Similarly, when discussing mortality rates Dr. Malas noted, "If you are a person with kidney failure in Texas you're in trouble, but if you're in New England you're golden." Consequently, geography and zip code appears to have a profound effect on patient survival, and this should not be the case.
Chronic Kidney Disease and Dialysis patients can take an active role in helping to improve their health outcomes. The most straight forward way of doing so is to use an AV Fistula. If you are currently using a catheter, discuss with your Nephrologists about transitioning to a safer option. If you cannot place a Fistula, consider requesting more information on a HeRO Graft which is not only used to salvage AV Fistulas, but can also be used as a chest catheter which is placed beneath the skin and has shown to be a lower risk for deadly infections (click here for more information).
Also Friends, help others. If you know someone at your clinic who is afraid of getting an AV Fistula, share your experience and answer any questions they may have. Dialysis patients in the Chronic Kidney Disease Community typically listen to their peers and trust them as much or in some cases even more than medical professionals. If you already have an AV Fistula and would like to know how you may help keep it functioning well, then click here.
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