A practical approach to vascular access for hemodialysis and predictors ofsuccess

Purpose: The long-term results and predictors of success for vascular acces s at The Toronto Hospital were studied. This report describes the access pr ogram and emphasizes the role of the vascular access coordinator. Methods: A total of 384 consecutive patients underwent 466 vascular access procedures. The access program is centered around a dedicated, full-time va scular access coordinator, who is a registered nurse and is responsible for all aspects of access care, including followup. Outcome variables were col lected prospectively. Primary, primary-assisted, and secondary success was determined by means of Kaplan-Meier analysis, and the stepwise Cox proporti onal hazards model was used for multivariate analysis of the factors that w ere independently predictive of primary success. Results: There were 235 autogenous arteriovenous fistulae (AVFs) and 231 ar teriovenous grafts (AVGs). The cumulative primary, assisted-primary, and se condary success (patent and functional for effective dialysis) at 24 months for all 466 cases combined was 36% +/- 3%, 54% +/- 3%, and 66% +/- 3%, res pectively. The primary success for AVFs and AVGs at 2 years was 54% +/- 4% and 18% +/- 4%, respectively (P < .001; log-rank test); the primary-assiste d success for AVFs and AVGs at 2 years was 62% +/- 4% and 44% +/- 6%, respe ctively (P < .001; log-rank test); and the secondary success for AVFs and A VGs at 2 years was 70% +/- 4% and 60% +/- 5%, respectively (P = .331; log-r ank test). Stratification of variables revealed significant benefit for AVF s (P = .001), the female sex (P = .014), and the absence of diabetes mellit us (P = .001). Multivariate analysis with Cox regression determined that ac cess type (AVF vs AVG; P = .001) and diabetes mellitus (P = .024) were inde pendently predictive of primary success. The improved clinical coordination of access patients with the initiation of the vascular access program resu lted in a significant reduction in length of hospital stay before and after the program was organized (2.5 +/- 0.06 vs 1.1 +/- 0.03 days; P = .001). Conclusion: The organization of a vascular access program in a practical an d cost-effective way for reduced length of hospital stay is streamlined thr ough a dedicated access coordinator, who ensures an integrated, multidiscip linary approach. The results for the Cox model is useful when discussing th e anticipated results of access procedures with individual patients.