Program Book - Keck School of Medicine of USC - University of ...

Needs AssessmentOver 370,000 patients in the United States require hemodialysis to sustain life. 1 Growth in theincident hemodialysis population has been driven by a linear increase since 1980. 1 In 2009, therewere 106,333 new hemodialysis patients. 1 Kidney Disease Outcomes Quality Initiative (K-DOQI)Clinical Practice Guidelines for Hemodialysis Adequacy have stated since 2006 that patients shouldhave a functional permanent access at the initiation of dialysis therapy. 2 However, 81% of patientsstill dialyze through a catheter at initiation of hemodialysis. 3 This may be related to the fact thatmany patients have challenging anatomy that make traditional arteriovenous fistulas or graftsdifficult to create.Advancements in biomedical engineering have accelerated the technological development andapplication of vascular access grafts. With the explosion of endovascular technology in vascularsurgery, many new grafts have been developed which use a combination of an open andendovascular approach to treating patients with challenging anatomy. This has resulted in morenon-catheter based hemodialysis access options.In 2003, the Fistula First Breakthrough Initiative was created with a goal of achieving a 70%prevalent fistula rate. 4 While the prevalent fistula rate has nearly doubled from 32% in 2003, as ofJanuary 2012, the prevalent national fistula rate is still only 60%. 5 One contributing factor to thefailure to achieve the 70% goal is that improvements in overall management of end-stage renaldisease patients have decreased the annual mortality almost 18% from 2000 to 2008. 1 However,during that same period, the prevalence of patients wait-listed for a kidney transplant increasednearly 33%. 1 As a result, the survival of this patient population increases at a rate that outpaces theavailability of kidney transplants. As survival increases without kidney transplantation, the availablesites for hemodialysis access creation become exhausted, increasing the challenge to the surgeon.In addition, with increasing patient survival, access complications also become more common.Advanced surgical techniques and endovascular technology have been increasingly applied totreatment of dialysis access complications so that the life of the hemodialysis access can beprolonged.Advances in technology combined with failure to meet national guidelines and the increasingprevalence of hemodialysis patients who pose a dialysis access challenge makes “Controversiesand Challenges in Hemodialysis Access” a timely topic for discussion and the subject of thisyear’s symposium. This course has been designed to update physicians and surgeons on themany new developments in vascular access grafts and techniques and to provide guidance as tohow these new management strategies should modify current practice patterns and achievenational guidelines.References1. U S Renal Data System, USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage RenalDisease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and KidneyDiseases, Bethesda, MD, 2011.2. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: HemodialysisAdequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 2006;48:S1-S322 (suppl 1).3. Slinin Y, Gui H, Gilbertson DT, et al. Meeting KDOQI Guideline Goals at Hemodialysis Initiation and Survival during theFirst Year. Clin J Am Soc Nephrol 5:1574-1581,2010.4. Neumann ME. “Fistula first” initiative pushes for new standards in access care. Nephrol News Issues 18:47-8,2004.5. Fistula first data. Available at http://www.fistulafirst.org/AboutFistulaFirst/FFBIData.aspx. Accessed .6.2012.2