Kidney Research UK

Background

Founded in 1961, Kidney Research UK (formerly the National Kidney Research Fund) is the largest funder of research into the prevention, treatment and management of kidney disease. Our mission is to improve the quality of life of those with kidney disorders and to increase public awareness of kidney health.

Patients with established renal failure (ERF) rely on transplantation or lifelong dialysis treatment to survive. ERF occurs when the kidneys cease to function properly, which is why, without a transplant, an artificial substitute in the form of dialysis is required to replace the lost function and so maintain life. We are therefore committed to raising awareness of the need not only to ensure that patients have access to dialysis treatment, but that they are also prepared in a timely and appropriate fashion to receive it.

Dialysis

There are two types of dialysis – Haemodialysis and Peritoneal Dialysis. The former is a process by which waste material and water are removed from the body pumping the blood through an artificial kidney linked to a dialysis machine. Patients usually receive this treatment at a hospital, but it can also take place at home. If, generally carried out three times a week, with each treatment taking about four hours.

Peritoneal dialysis uses the natural membrane in the abdomen (the peritoneum) for dialysis. A sterile fluid is run into the abdomen. Waste products are drawn into the fluid. This fluid is then drained out and fresh fluid instilled. This process may be carried out manually (called CAPD – Continuous Ambulatory Peritoneal Dialysis) or using an automated machine overnight (APD). This form of dialysis only takes place at home and therefore gives patients greater freedom in their lifestyle.

Vascular Access

In both cases, a means of entry into the body (or access) is required to carry out the treatment. Peritoneal access involves a soft tube being inserted permanently into the patient’s abdomen through which the fluid is run.

In the case of haemodialysis, which requires access to the bloodstream, entry can be achieved temporarily by placing an artificial tube, known as a central venous dialysis catheter, into one of the large veins in the neck or in the groin. This method is not without problems. First, there is an increased risk of infection, which can have serious consequences. Second, the catheter may block, reducing the quality of the dialysis treatment. Third, in the long term, catheters can damage the veins.

For most people, the best form of access is called a ‘fistula’. This is constructed by joining together a vein and an artery surgically under the skin, usually in the forearm. This provides a fast flowing stream of blood within the enlarged vein. This vein allows needles to placed so that someone can have haemodialysis. Fistulas offer a better quality of dialysis, since more blood can be processed, tend to last longer than other forms of access and have a much lower risk of infection than catheters.

Fistulae do need time to develop or ‘mature’ once made, and so needs to be done at least 6-12 weeks before dialysis needs to start. Dialysis is then undertaken by inserting two needles into the fistula, which are attached to the dialysis machine by sterile tubing. Blood flows out of the fistula through one needle to the artificial kidney and then back to the fistula through another tube and needle further up the arm, thereby removing excess fluid and waste products.

Vascular Access Survey

There is strong evidence to suggest that permanent vascular access should be established before starting dialysis. This avoids the need for central venous catheter and allows the fistula to be used when dialysis starts and reducing the risk of problems for the patient.

The National Service Framework for Renal Services included a standard on vascular access to ensure that patients with established renal failure have timely and appropriate surgery for permanent vascular or peritoneal access. To achieve this, it called for early referral of patients for assessment of the best means of access; monitoring and early intervention to minimise complications; the replacement of temporary access with a permanent solution as soon as possible; and proper training of health professionals and patients in the care of the access route.

We greatly welcomed these recommendations and are keen to ensure that theseare implemented in full across the country. In 2005, Kidney Research UK and the Renal Association set up a specially-created steering group comprising experts from around the country to conduct an audit of vascular access services by requesting information from all renal units in the UK. The aims were to determine how patients received their treatment, how well prepared were patients for dialysis and to assess the complication rate for patients receiving haemodialysis.

Preliminary results released in early 2006 did indicate insufficient preparation of patients starting dialysis. Data from 90% of the units surveyed showed that only 43% of patients started renal replacement therapy using ideal vascular access, and for haemodialysis patients, this figure was just 31%. Many factors appeared to influence the preparation of patients. There were three areas of concern. First many patients were identified late. Second, there was a delay in referring patients for access surgery. Third, services lacked capacity were organised poorly.

Furthermore, the results show that amongst haemodialysis patients infection and admission for renal problems were. One in twenty haemodialysis patients were occupying hospital beds, equating to over 320,000 bed days a year. Serious MRSA infections were recorded in 4% patients in a year and that patients on haemodialysis potentially make up up to 10% of all MRSA cases in England and Wales.

Recommendations to improve vascular access services

The current reality therefore falls a long way short of the best practice guidance set out in the Renal NSF. The challenge now is to deliver improvement to meet the Government’s standard to ensure timely and appropriate vascular access surgery across the country.

We therefore support the recent recommendations of the Renal Association, Vascular Society and British Society of Interventional Radiology working group, which were produced following the findings of the vascular access survey. These include measures to improve capacity, such as increasing the number of day case procedures carried out under local anaesthetic; streamlining the patient pathway to improve referral rates and reduce waiting lists; and recommendation of best clinical practice, including: when to perform surgery, how and when to monitor access, and how to audit outcomes.

Kidney Research UK

April 2007