TITLE: Analysis of the vascular access service for patients on haemodialysis in Livingstone Hospital

BACKGROUND: Reliable vascular access is key to sustainable haemodialysis treatment. Guidelines recommend an arteriovenous fistula (AVF) as the preferred modality in preference to arteriovenous grafts (AVGs) or central venous catheters (CVCs). There are limited data on vascular access in sub-Saharan Africa. This study aimed to evaluate the vascular access used in a South African tertiary hospital and identify problems with achieving the recommended access goals.

METHODS: A cross-sectional analysis was performed of the haemodialysis programme at Livingstone Tertiary Hospital. Current and initial vascular access used, timing until the creation of permanent access, and any complications experienced were recorded.

RESULTS: CVCs were used in 56% of subjects, 38% were using an AVF and 5% were using an AVG. Only 12% of the group had no AVF attempt. The overwhelming majority (95%) had dialysis initiated with a CVC. The rate of pre-emptive AVF creation was low and a delay in AVF creation was seen in 63% of patients. Central venous stenosis or occlusion was present in 26% of patients and likely due to prior or current CVC use.

CONCLUSIONS: The prevalence of CVC use was high and there were significant delays to AVF creation. High rates of central venous stenosis compromise future AVF use and are likely due to prolonged CVC use. Changes needed to improve the vascular access service include a multidisciplinary access clinic, dedicated theatre list, vascular access co-ordinator and further data collection to continually evaluate the vascular access service.

SOURCE: Grant IR, Freercks RJ, Honiball EJ, et al. Analysis of the vascular access service for patients on haemodialysis in Livingstone Hospital[J]. Cardiovasc J Afr, 2020, 31:1-4. DOI: 10.5830/CVJA-2020-049. 

背景：可靠的血管通路是持续进行血液透析治疗的关键。指南建议动静脉内瘘（AVF）作为首选方式，而不是动静脉移植物（AVG）或中心静脉导管（CVC）。在撒哈拉以南的非洲，有关血管通路的数据有限。这项研究旨在评估南非三级医院中使用的血管通路，并发现在实现建议的通路目标方面存在的问题。

方法：在利文斯通三级医院对血液透析程序进行横断面分析。记录当前和最初使用的血管通路，建立永久通路之前的时间以及遇到的任何并发症。

结果：56％的受试者使用了CVC，38％的患者使用了AVF，5％的患者使用了AVG。该组中只有12％的人没有进行AVF尝试。绝大多数（95％）的患者以CVC开始透析。预先建立的AVF产生率低，在63％的患者中出现了AVF延迟建立。 26％的患者存在中心静脉狭窄或闭塞，可能是由于先前或当前使用了CVC。

结论：CVC的使用率很高，并且AVF的建立存在明显的延迟。中央静脉狭窄的高发生率不利于未来AVF的使用，并且可能是由于CVC的长期使用所致。改善血管通路服务所需的变化包括多学科通路诊所，专门的手术列表，血管通路协调员以及进一步收集数据以不断评估血管通路服务。

启发：应尽量减少CVC的使用，可减少中心静脉狭窄或闭塞的发生。有利于AVF的长期使用。