Alternative Practices to Simultaneously Placing a Peritoneal Dialysis Catheter and Arteriovenous Fistula
Nephrologists often recommend concurrently placing an arteriovenous fistula (AVF) with a peritoneal dialysis catheter (PDC) in patients who are starting dialysis therapy on peritoneal dialysis (PD). This approach ensures that a back-up access is in place if PD were to fail. While this may be necessary for certain high-risk patients (e.g., those with low Kt/V, low albumin, higher hospitalization rate and frequent peritonitis), there are other approaches that can help increase the chances of a patient succeeding on PD and negate the need for an AVF.
Concerns with simultaneously placing a PDC and AVF
The first reason to consider an alternate approach to simultaneously placing a PDC and AVF involves preserving the patient’s blood vessels. There is no guarantee the fistula will ever be used (due to success with PD or an eventual kidney transplant), and a premature AVF placement eliminates vascular options that may be needed in the future. Second, placing an AVF can lead to complications and AVF failure, particularly among elderly and diabetic dialysis patients. The diabetic patient is particularly at greater risk for complications, such as vascular thrombosis and poor AVF maturation. The third reason relates to the psychological message AVF placement may send from provider to patient. The very practice of placing a back-up access may undermine the success of PD by assuming the modality will fail. A lack of confidence in PD (from provider and patient) may result in non-adherent behaviors and a propensity to abandon the modality prematurely—despite its many potential advantages and benefits.
Alternative practices to simultaneous PDC-AVF placement
Instead of prematurely assuming PD will fail and planning for a transition to hemodialysis, it is better to focus on ways to help improve the odds of PD success in the following ways.
Care team involvement. The care team is highly critical to the success of PD. Care teams, led by nephrologists, are responsible for effectively educating patients on kidney disease and providing them with the appropriate PD training. The team frequently follows up with patients during the first 90 days to ensure the patients are receiving the support and information they need to help them succeed on PD. In addition, the care team continuously analyzes laboratory tests and proactively addresses any potential issues with the therapy. If the nephrologist, in partnership with the care team, determines the patient is at risk for complications, or the current therapy is not helping to control risk factors, then it is time to proactively transition the patient to a different modality. As is the case with all complex patients, dialysis patients require team oversight and highly coordinated care to facilitate optimal outcomes (oversight that, in general, occurs more often in larger PD programs.
Telemedicine. One of the best methods by which care teams can engage with and track patient health is via telemedicine and remote monitoring. The increased connectivity available through virtual visits, as well as biometric data, allows for a better understanding of how patients are doing on the modality and an early intervention when complications arise.
Predictive analytics. Predictive analytic tools are also key to cultivating PD success. Risk stratification of patient cohorts can reveal which patients are most vulnerable—at high risk or rising risk—to complications. As with telemedicine, risk modeling allows for early intervention and is key to helping avoid adverse health events.
Placing a PDC and AVF simultaneously may be necessary for certain high-risk patients. If there is evidence of a higher propensity for PD failure, concurrent access placement is appropriate. High-risk patients who are not prepared with an AVF may initiate hemodialysis emergently—using the least-desirable central venous catheter (CVC) access. For other patients starting dialysis on PD, it is often appropriate to delay AVF placement and, instead, focus attention on supporting the success of PD. This allows for the provision of optimal care: the right therapy, for the right patient, at the right time.