New Research Examines Care Practices in Place for Dialysis Patients

CINCINNATI—Researchers at the University of Cincinnati and the Cincinnati Department of Veterans Affairs (VA) Medical Center have received funding to study the care processes that lead to placement of arteriovenous fistulas in patients beginning dialysis.

Timmy Lee, MD, UC Health nephrologist, staff VA physician and lead investigator on the study, was awarded the National Kidney Foundation’s Young Investigator Award—totaling $150,000 over three years—to look at ways to improve access placement in patients starting dialysis for the first time.

"There are two main types of permanent dialysis access: an arteriovenous fistula (AVF), which connects the artery and the vein directly, and an arteriovenous graft, which connects the artery and the vein using a plastic tube,” he says. "AVFs are the best form of access because fewer interventions are needed in order to keep the access area open once functional, and fewer infections occur compared to grafts; however, less than 20 percent of dialysis patients use AVFs on their first dialysis session.  National guidelines are seeking to achieve a goal of 50 percent of patients starting dialysis with a functional AVF.

"In this observational study, we will examine the processes of care that get patients to the point of having an AVF implanted when they start dialysis, such as early referral from a patient’s internist to their nephrologist and physicians’ discussions with patients about dialysis options, time of examination of their veins and arteries with ultrasound, referral to a surgeon for fistula placement, and placement of a fistula before dialysis is needed.”

Nephrologists and surgeons at the VA will also initiate a multi-disciplinary clinic to deliver comprehensive care to patients with advanced chronic kidney disease. These nephrologists and surgeons are already operating a vascular access clinic at the VA.

Lee says both of these initiatives will be examined for their effect on improving the rate of successful placement of preferred vascular access, and researchers will compare historical data with the results from the initiation of these two new clinics.

This project will be completed at the VA.

"We will look at the level of kidney function when preoperative ultrasound mapping occurs—a tool which allows physicians to look at the vessel size to determine if an AVF is the right fit for the patient—and level of kidney function when surgeon referral and surgical placement occurs,” he says. "We’re specifically trying to pinpoint a breakdown in the steps to see if it can be prevented. Furthermore, we believe that these newly developed clinics will improve processes of care measures.”

"We hope that this research and our patient care clinics dedicated to vascular access care will greatly improve results for this subgroup,” he continues. "There are over 450,000 people undergoing hemodialysis in the United States. If we tweak the way we are doing things to prevent the need for added surgeries and interventions, we will be positively impacting lives all over the world.”

Charuhas Thakar, MD, associate professor of medicine at UC and chief of the renal section at the Cincinnati VA Medical Center, is a co-collaborator on the study. Lee’s mentor for this grant is Prabir Roy-Chaudhury, MD, PhD, UC Health nephrologist, staff VA physician and professor of medicine at UC. 

Lee is also a member of the Cincinnati Dialysis Access Program, a translational research group at UC dedicated to improving the care of dialysis access in patients with kidney disease.