What should be the role of nephrologist in

What should be the role of nephrologist in the care of vascular access? Marko Malovrh Ljubljana Slovenia

ISN CME Course „Nephrology Update 2016“ Disclosure of speaker’s interests Conflict of Interest None Financial Relationships None 2

Objectives �Current situation and trends of VA in the world �Short history about the role of nephrologists �Preoperative period – from the findings of CKD to the decision on the type and construction of vascular access �Surgical construction – when, how and who? �Post-operative surveillance – when, who and how? �Complications �Cannulation of AVF or graft �Conclusions 3

Vascular accesses in prevalent patients Catheter AVG AVF Italy Germany France Spain Belgium I = 1996 -2001; II= 2002 -2003; III = 2005 -2007 (DOPPS); IV- 2010 -2012 (DOPPS) 4

Vascular accesses in prevalent patients Catheter AVG AVF Sweden UK Japan ANZ Canada US I = 1996 -2001; II= 2002 -2003; III = 2005 -2007 (DOPPS); IV- 2010 -2012 (DOPPS) 5

Vascular accesses at incident HD patients Vascular accesses use, by country among incident HD patients (DOPPS data 1996 -2010) 6

Nephrologists are traditionally educated: �Kidney physiology and patho-physiology �Management of kidney diseases �Familiar with renal anemia, ostreodystrophy, heart diseases and many others disorders of ESRD �Initiate and supervise dialysis treatment �Care for pts before and after kidney transplantation �Should be also educated to recognize the pivotal role of VA for hemodialysis patients and to be proactive in VA acitvities 7

Nephrologists were involved historically into VA problems in the early years of HD treatment: 8

1965/66 2004 -2008 1970 An upper arm A-V fistula for hemodialysis patients with distal access failures Someya S, Bergan JJ, Kahan BD, Yao ST, Ivanovich P. Trans Am Soci Artif Intern Organs. 1976; 22: 398403. Stapler for A-V anastomosis: simplified, immediate vascular access. Ivanovich P. Kahan BD, Someya S, Bergan JJ, et al. Trans Am Soci Artif Intern Organs 1977; 23: 716 -718. Dr. Klaus Korner Germany • More than 5000 procedures • Many technical inovations • In Italy • In India 9

�First AVF construction 7. 1. 1974 by nephrologist �First Goretex graft: 30. 1. 1978 by nephrologist Dr. Henrik Mulec Dr. Jože Drinovec 10

NEPHROLOGISTS-SURGEONS OF VA IN UKC LJUBLJANA dr. Jože Drinovec - dr. Radoslav Kveder - dr. Rafael Ponikvar 1974 -1990 1980 -1999 1980 - dr. Alenka Urbančič 1989 - 2004 dr. Vladimir Premru 1997 - dr. Marko Malovrh 1986 - 2014 dr. Boštjan Kersnič 2004 – SB Trbovlje 11

Prevalent patients in Slovenia Adapted from: Buturovic-Ponikvar J, et. al. Ther Apher Dial 2016 Jun; 20(3): 223 -8. 12

Incident patients Adapted from: Buturovic-Ponikvar J, et. al. Ther Apher Dial 2016 Jun; 20(3): 223 -8. 13

Percent catheter use in pts first seeing by nephrologist prior initiating dialysis Adapted from: Either, et. al. NDT 2008; 23: 3219 -3226. 14

Patient survival in four groups Lorenz et al. Am J Kidney Dis 2004: 43; 999 -1007. 15

Nephrologists have to be involved in VA activity at different periods of CKD, HD, CAPD and Tx pts: - Early and late period of CKD, - Pre-dialysis period, - Period before surgery, - Period of VA creation, - Period of VA maturation, - Following of VA function during HD treatment and after tx kidney 16

Role of nephrologist in creation of VA: - To achieve a functional and permanent VA – VA creation plan is crucial. - Early care by nephrologist-VA surgeon or early referral to VA surgeon has a clear benefit for incident patient in achieving a timely initial VA creation so that the VA can be used at initiation of HD therapy. - Choice of strategy should be guided by assessment of individual’s rate of CKD progression to avoid excessively early or late referrals. 17

Role of nephrologists in early, late period of CKD and in pre-dialysis period: 18

No CKD patient e. GFR ≤ 30 m. L/min Malovrh M. Contrib Nephrol. 2015; 184: 13 -23. Yes Vein preservation: Clinical examination - educational program for Preservation of veins patients, nurses and physicians Physical examination of vessels Medical history and concomitant diseases: - Age - Gender - Hypertension - Diabetes - Cardiac diseases - Peripheral arteries diseases Veins Arteries Quality of arterial -Education programme of patients, nurses and pulse - Blood pressure at both physicians arms Tourniquet placed: - Visibility Continuity Distension - Side braches - Arm or thoracic collaterals - - Allen test Duplex ultrasound VEINS - Internal diameter (>2 -2. 5 mm) - Internal diameter with inflated cuff – increasing for ≥ 0. 4 mm or > 15% (distensibility) (Figure 3) - Depth of vein ≤ 6 mm - Quality of vein wall – no fibrotic changes - No side branches or ligation them during surgery - Changing of Doppler waveform during respiration increasing during inspiration (Figure 4) ARTERIES - Internal diameter (>2 -2. 5 mm) - Calcification (severe-move towards upper part of forearm) - Doppler flow velocity (≥ 25 cm/s) - Resistance index (RI) at reactive hyperemia≤ 0. 7 or change of HRF to LRF (Figure 5) 19

Preservation of veins: �Do not use veins at the upper arm for blood samples or infusions �Do not use central vein catheters �Excercises for increasing of veins

CKD patient e. GFR ≤ 30 m. L/min No Yes Vein preservation: Clinical examination - educational program for patients, nurses and physicians Physical examination of vessels Medical history and concomitant diseases: - Age - Gender - Hypertension - Diabetes - Cardiac diseases - Peripheral arteries diseases Medical history Veins Arteries Tourniquet placed: - Visibility - Continuity - Distension - Side braches - Arm or thoracic collaterals - Age - Gender - Arterial hypertension - Diabetes - Heart diseases - Periheral artery diseases VEINS - Internal diameter (>2 -2. 5 mm) - Internal diameter with inflated cuff – increasing for ≥ 0. 4 mm or > 15% (distensibility) (Figure 3) - Depth of vein ≤ 6 mm - Quality of vein wall – no fibrotic changes - No side branches or ligation them during surgery - Changing of Doppler waveform during respiration increasing during inspiration (Figure 4) - Quality of arterial pulse - Blood pressure at both arms - Allen test Duplex ultrasound ARTERIES - Internal diameter (>2 -2. 5 mm) - Calcification (severe-move towards upper part of forearm) - Doppler flow velocity (≥ 25 cm/s) - Resistance index (RI) at reactive hyperemia≤ 0. 7 or change of HRF to LRF (Figure 5) 21

No CKD patient e. GFR ≤ 30 m. L/min Malovrh M. Contrib Nephrol. 2015; 184: 13 -23. Yes Physical examination of veins Vein preservation: Clinical examination - educational program for patients, nurses and physicians Physical examination of vessels Medical history and concomitant diseases: Veins Proximal compression: - Visibility - Continuity - Distension - Side branches - Arm or thoracic collaterals - Age - Gender - Hypertension - Diabetes - Cardiac diseases - Peripheral arteries diseases Arteries Tourniquet placed: - Visibility - Continuity - Distension - Side braches - Arm or thoracic collaterals VEINS - Internal diameter (>2 -2. 5 mm) - Internal diameter with inflated cuff – increasing for ≥ 0. 4 mm or > 15% (distensibility) (Figure 3) - Depth of vein ≤ 6 mm - Quality of vein wall – no fibrotic changes - No side branches or ligation them during surgery - Changing of Doppler waveform during respiration increasing during inspiration (Figure 4) - Quality of arterial pulse - Blood pressure at both arms - Allen test Duplex ultrasound ARTERIES - Internal diameter (>2 -2. 5 mm) - Calcification (severe-move towards upper part of forearm) - Doppler flow velocity (≥ 25 cm/s) - Resistance index (RI) at reactive hyperemia≤ 0. 7 or change of HRF to LRF (Figure 5) 22

No CKD patient e. GFR ≤ 30 m. L/min Yes Malovrh M. Contrib Nephrol. 2015; 184: 13 -23. Physical examination of arteries Vein preservation: Clinical examination - educational program for patients, nurses and physicians Physical examination of vessels Medical history and concomitant diseases: - Age - Gender - Hypertension - Diabetes - Cardiac diseases - Peripheral arteries diseases - Quality of pulse Veins Tourniquet placed: - Visibility - Continuity - Distension - Side braches - Arm or thoracic collaterals Arteries - Quality of arterial - Blood pressure on both arms Duplex - Allen test? ? ? ultrasound VEINS - Internal diameter (>2 -2. 5 mm) - Internal diameter with inflated cuff – increasing for ≥ 0. 4 mm or > 15% (distensibility) (Figure 3) - Depth of vein ≤ 6 mm - Quality of vein wall – no fibrotic changes - No side branches or ligation them during surgery - Changing of Doppler waveform during respiration increasing during inspiration (Figure 4) pulse - Blood pressure at both arms - Allen test ARTERIES - Internal diameter (>2 -2. 5 mm) - Calcification (severe-move towards upper part of forearm) - Doppler flow velocity (≥ 25 cm/s) - Resistance index (RI) at reactive hyperemia≤ 0. 7 or change of HRF to LRF (Figure 5) 23

CKD patient e. GFR ≤ 30 m. L/min No Yes Malovrh M. Contrib Nephrol. 2015; 184: 13 -23. Duplex ultrasound Vein preservation: - educational program for Clinical examination patients, nurses and physicians Physical examination of vessels Medical history and concomitant diseases: VEINS - Internal diameter(>2 -2. 5 mm) - Age - Gender - Hypertension - Diabetes - Cardiac diseases - Peripheral arteries diseases Veins Tourniquet placed: - Visibility - Continuity - Distension - Side braches - Arm or thoracic collaterals Arteries - Internal diameter after compression– increase for ≥ 0. 4 mm ali > 15% (distensibility) - Depth of vein (≤ 6 mm)? ? Duplex - Quality of vein wall – no fibrosis ultrasound - No side branches VEINS ARTERIES - Change of Doppler signal during deep inspiration Internal diameter (>2 -2. 5 mm) Internal diameter with inflated cuff – increasing for ≥ 0. 4 mm or > 15% (distensibility) (Figure 3) - Depth of vein ≤ 6 mm - Quality of vein wall – no fibrotic changes - No side branches or ligation them during surgery - Changing of Doppler waveform during respiration increasing during inspiration (Figure 4) - Quality of arterial pulse - Blood pressure at both arms - Allen test Internal diameter (>2 -2. 5 mm) Calcification (severe-move towards upper part of forearm) - Doppler flow velocity (≥ 25 cm/s) - Resistance index (RI) at reactive hyperemia≤ 0. 7 or change of HRF to LRF (Figure 5) 24

CKD patient e. GFR ≤ 30 m. L/min No Yes Malovrh M. Contrib Nephrol. 2015; 184: 13 -23. Duplex ultrasound Vein preservation: Clinical examination - educational program for patients, nurses and physicians Physical examination of vessels Medical history and concomitant diseases: Arteries - Internal diameter(>2 -2. 5 mm) - Age - Gender - Hypertension - Diabetes - Cardiac diseases - Peripheral arteries diseases Veins Tourniquet placed: - Visibility - Continuity - Distension - Side braches - Arm or thoracic collaterals Arteries - Quality of arterial pulse - Blood pressure at both - Calcifications arms Allen test - Doppler flow velocity (> 25 cm/s) - RI at reactive hyperemia<0. 7 Duplex or change of HRF to LRF ultrasound VEINS - Internal diameter (>2 -2. 5 mm) - Internal diameter with inflated cuff – increasing for ≥ 0. 4 mm or > 15% (distensibility) (Figure 3) - Depth of vein ≤ 6 mm - Quality of vein wall – no fibrotic changes - No side branches or ligation them during surgery - Changing of Doppler waveform during respiration increasing during inspiration (Figure 4) ARTERIES - Internal diameter (>2 -2. 5 mm) - Calcification (severe-move towards upper part of forearm) - Doppler flow velocity (≥ 25 cm/s) - Resistance index (RI) at reactive hyperemia≤ 0. 7 or change of HRF to LRF (Figure 5) 25

Role of nephrologist in period of surgery: - Cooperation with vascular surgeons - Cooperation with nephrologists-vascular access surgeons

RADIOLOGIST VASCULAR SURGEON NEPHROLOGIST - depends from tradition - interes of surgeons - financial situation etc. DIALYSIS NURSE

NEPHROLOGIST VA SURGEON ULTRASOUND DIALYSIS PHYSICIAN

Who should perform VA surgery? �In the world there are no uniform views �Mostly surgical VA programme are: �Performed by young surgeons �Without continuity �Small and less spectacular surgery

Advantages of system “nephrologist-access surgeon”: • Physical and US evaluation of patient by dedicated nephrologists • On time planned VA construction • Surgery could be done at any time: no dependence on capacity of operating theaters and anesthesia teams • In case of VA dysfunction, surgical intervention like thrombectomy, can be done immediately after finding before starting HD and after successful intervention HD can be started on same day without use of CVC 30

Nephrologist – VA surgeon: Yes or No? Yes �If they are interested in and have manual skills �Education at VA surgeon or nephrologist-VA surgeon with experience is required �At least 100 interventions is needed, attraction of VA surgery becomes between 300 and 500 operations �Awareness of risiko is important: "winning" and ”loosing" are very close "neighbors" �Self-criticism and modesty is important No �If all this is not �If a good cooperation with the surgeons

Role of nephrologist in period after VA construction: -Period immediately after surgery -Period of maturation 32

Period immediately after VA construction: VA could stop to work: • Spasm • Hypotension • Disturbed outflow by vein compression Following VA function by periodic : • Palpation of thrill • Listening of bruit Early intervention by a gentle massage, infusion of plasma expander and heparin i. v. could be useful 33

Period of VA maturation: �Critical first 4 weeks �Dialysis nurses and nephrologists should evaluate VA clinically to determine whether it has mature sufficiently to use for HD �Early diagnostics and intervention for fistula maturation minimize catheter use and its associated complications

Role of nephrologists following of VA function during HD treatment: q Nephrologists should be trained to recognize VA problems: o To pay attention on the quality of HD treatment based on clinical signs and laboratory tests o Post-puncture bleeding o Decrease or critical reduction of arterial blood flow or increase of venous pressure during HD 35

Role of nephrologists following of VA function during HD treatment: q Each VA should be evaluated by physical examination before cannulation at each HD treatment. q Physical examination is easily learned, easily performed, quickly done and economical. q US is an additional diagnostic method for detection of these problems early and progression can be prevented by interventional radiology or surgery. 36

Pysical examination �Palpation of thrill �Listening of murmur

Late complications of functioning and used AVF �Thrombosis �Vein (outflow) stenosis �Ischemia �Aneurysm and pseudoaneurysm �Infection �Recirculation 38

Clinical evaluation of stenosis 39

Central vein stenosis

Physical examination of side branches and their importance:

Clinical evaluation of recirculation § § The pressure on the vessel or graft between the two needles in the course of HD In the normal state, the changes are minimal or not at all 45

Recirculation as a consequence of disturbances in the drain (venous stenosis) § Venous pressure will be increased, § Arterial pressure becomes somewhat more negative - less the flow from venous part 46

Recirculation as a consequence of poor inflow (arterial stenosis or bad artery) § Arterial pressure drops - more negative due to reduced inflow from venous part § Venous pressure does not change or very little The investigation is not possible, if the reason is excessively close of the needles 47

Role of nephrologist in checking of VA cannulation The rope ladder pattern The area puncture pattern The buttonhole pattern 48

CONCLUSION 1. Besides specific therapy of CKD patients, nephrologists at their daily work are faced with the problem of VA at these patients when they will need treatment or are already treated with chronic HD. 49

CONCLUSION 2. Placement and adequate maturation of VA before initiation of HD therapy require: Timely patient and staff education and counseling, including vein preservation Selection of preferred renal replacement modality Physical and ultrasound assessment of vessels Selection of VA type and location Creation of VA at least several weeks or months in advance of its expected need . 50

CONCLUSION 3. In an ideal situation, creation of VA is an interdisciplinary task and nephrologists are who integrates the activities of dialysis nurse, ultrasonographer, surgeon and interventional radiologist. 51

CONCLUSION 4. In no such ideal situation and lack of interested surgeons, nephrologists have to be involved in physical examination, noninvasive ultrasound examination and VA surgery. 52

CONCLUSION 5. Monitoring of VA by nephrologist and dialysis nurse should be performed prior to each cannulation by physical examination to detect low flow, hyperpulsatility, abnormal thrills or bruits and skin lesions. In this way, we can achieve timely intervention and prevent final failure of VA. 53

Start of treatment? Dialysers ? Choice of method? Therapy? Machines? AV fistula or graft? !! Diagnostic ? ?

THANK YOU FOR YOUR ATTENTION Ljubljana is inviting you at 10 th VAS Congress in April 2017 55