Vascular Access Profile of Haemodialysis Patients at Kenyatta National Hospital
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Date
2021Author
Bwombengi, Joyce K
Type
ThesisLanguage
enMetadata
Show full item recordAbstract
Background
There is a rapidly growing population of patients with end stage kidney disease on
hemodialysis in Kenya. The vascular access is a hemodialysis patients’ lifeline. Ideal vascular
access planning should begin in the early stages of chronic kidney disease before the patient
requires dialysis. Decisions surrounding the choice of vascular access and the timing for its’
creation are complex. Descriptive data on the process of referral and timing for access creation,
types of access utilized, the processes of access creation, after care and management of access
complications, vascular access related morbidity and socioeconomic determinants should be
documented in order to inform vascular access practice in Kenya.
Objective
Document the vascular access profile of haemodialysis patients at Kenyatta national hospital
and document the factors that determine their choice of vascular access.
Methods
This was a hospital based descriptive cross-sectional study that evaluated adult patients
undergoing hemodialysis for end stage kidney disease for more than three months at the
Kenyatta National Hospital Renal Unit. Consecutive sampling was employed to recruit 80
participants. Eligible participants who gave written consent were interviewed via an
investigator administered questionnaire to document vascular access types utilized and the
individual participants’ vascular access score as the denominator.
Results
Between January and March 2021, 80 patients who were undergoing regular hemodialysis for
ESKD were invited to participate in this study. The participants were predominantly young
persons below forty years of age (50.1%) with a comparable number of male to female
participants. The distribution of the incident vascular accesses was the non-tunneled central
venous catheter (ntCVC)(77.5%), tunneled central venous catheter (tCVC)(20%) and the
arteriovenous fistula (AVF)(2.5%) in descending order of frequency. The distribution of
prevalent vascular accesses was tCVC (42.5%), CVC with maturing AVF (20%), AVF
(18.8%), ntCVC (17.5%) and bridging CVC in a patient on peritoneal dialysis (1.25%)
The AVF was the least used vascular access in either group.
The median number of access per participant was two with a range of 1 to 20 (n=235). The
vascular accesses participants utilized most during their dialysis vintage was a ntCVC(48.5%).
The right internal jugular vein was the most common site used for CVC placement RIJntCVC
(25.6%), RIJntCVC (21.8%)while the left brachiocephalic region was the most common
location for AVF placement (10.3%).
38.3% of the participants reported having a problem with their current vascular access with the
reported vascular access complications included vascular access infection, vascular access
dysfunction and vascular access related pain and vascular access bleeding that required
transfusion (51.6%, 45.2% and 25.8%, 6.5%) respectively.
The mean VAQ score was 17.0. There were significantly better (lower) VAQ scores in
participants who had an AVF (9.4, p=0.007), those who were single (13.6,p=0.041) those who
had not had a problem with their vascular access in the last one year (14.1, p=0.002) and those
were very satisfied with their current VA (11.4 p=0.001).There were lower VAQ scores at the
extremes of age, amongst those with tertiary level of education(14.7) and those who had a
dialysis vintage of more than 2 years(14.7).There were worse (higher) VAQ score in female
participants (19.1) and those who had diabetes mellitus (18.9). The VAQ score was comparable
in participants who had an AVF in either the dominant or nondominant arm.
Various factors were identified as possible contributors to the choice of vascular access. Most
participants were referred late for nephrology and vascular access services. 77.5% reported
initiation on HD within three months of being diagnosed with ESKD, 85% were initiated on
HD as an emergency while 85% had their incident vascular access placed as an emergency.
75% reported being reviewed by a nephrologist within a 3 month period prior to initiation of
HD, 21.3% were reviewed by a nephrologist at least 3 months prior to initiation of HD while
7.5% were reviewed by a vascular access surgeon at least 3 months prior to initiation of HD.
Only 7.5% had an AVF attempted prior to initiation of HD.
At initiation of HD, 18.8% were not aware of any forms of KRT, 62.5% were only aware of
HD and only 7.5% reported being aware of the various vascular access types. 58 (73.1%) of
the participants were aware of the advantages of AVFs over CVCs and listed them as having
less access related infections, better blood flows, ease of bathing, access longevity, aesthetic
appeal and ease of conjugal activities ((n= 58) 93.1%, 81%, 39.7%, 36.2%, 3.4% and 1.75%
respectively).Their source of information on KRT and vascular access types was from the
dialysis nurses, doctors and fellow patients (78.9%, 73.7% and 23.7% respectively).
All the participants reported that their first vascular access was recommended by their doctor.
Subsequently, almost a half of them (43.8%) had a change of their vascular access within the
first 3 months of initiation of HD because of the need to get a definitive vascular access(56.5%),
due to vascular access infections (30.4%), access failure (28.8%) and vascular access extrusion
(13%). The most common vascular access converted to was a tCVC (48.9%), followed by
ntCVC (37.8%) and AVF least (13.3%). About a fifth (n=17, 21.3%) reported having vascular
access related hospitalization in the last one year. The reasons for hospitalization included
vascular access infections (61.1%), vascular access bleeding (22.2%) and superior venacava
syndrome (11.1%).
At the time of the study, 59 participants (73.7%) were using a CVC for HD though majority of
them (84.7%) reported having been advised to get an AVF. The reasons listed for not having/
using an AVF included long uncoordinated processes (32%), having a previous AVF that never
worked (28%), long surgery waiting times (20%), having a CVC therefore seeing no need for
another access (18%), financial constraints (16%), having an AVF that was yet to mature
(16%), having unsuitable blood vessels (12%) and feeling that an AVF would interfere with
their occupation (4%).
About a half of the study participants (n= 38, 47.5%) reported having an AVF placement during
their dialysis vintage. Of these, a fifth (18.5%) had an AVF in their dominant arm with resultant
discomfort in 36.4% reported as difficulty conducting household chores (75%) and/or changes
in sensation (50%). 18 (22.5%) of our participants reported a previous AVF that failed.
2,(11.5%) were offered a corrective procedure and 77.8% were willing to get another AVF.
Most participants were satisfied with their current access (83.8%) and felt that their access was
easy to use (92.5%). More than half (68.8%) would recommend their current access to a fellow
patient. The vascular access most preferred was the AVF (68.8%). 11.3% did not know which
vascular access they preferred while 6.3% had no preference. Most participants felt that the
nurses preferred an AVF (65%).
Conclusion This study demonstrates that most participants were young persons expected to be at the peak
of their productivity and hence an optimal vascular access is crucial to their ESKD management
and their vascular access health related quality of life. The AVF is the least common vascular
access in either incident or prevalent accesses, yet it is the most preferred access by both
patients and dialysis nurses and has better VAQ scores. Non tunneled CVC is the predominant
incident vascular access type while the tunneled CVC is the predominant prevalent access type
and this is most likely due to late referral for nephrology and vascular access care, low levels
of predialysis patient education and systemic barriers in vascular access acquisition and
maintenance. Individualized vascular access placement should consider the patients’
preference, their comorbidities, previous vascular access experience, their socioeconomic
determinants and their vascular access related quality of life. A vascular access coordination
team is key to ensure optimal individualized vascular access outcomes.
Publisher
University of Nairobi
Rights
Attribution-NonCommercial-NoDerivs 3.0 United StatesUsage Rights
http://creativecommons.org/licenses/by-nc-nd/3.0/us/Collections
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