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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 2, March/April 2021
98
AFRICA
Analysis of the vascular access service for patients on
haemodialysis in Livingstone Hospital
Ian R Grant, Robert J Freercks, Eduard J Honiball, Bhekifa Dube
Abstract
Background:
Reliable vascular access is key to sustainable
haemodialysis treatment. Guidelines recommend an arterio-
venous 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 crea-
tion 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.
Keywords:
arteriovenous fistula, haemodialysis access, arterio-
venous graft, tunnelled central venous catheter
Submitted 10/11/19, accepted 2/10/20
Published online 11/11/20
Cardiovasc J Afr
2020;
31
: 98–101
www.cvja.co.zaDOI: 10.5830/CVJA-2020-049
Haemodialysis offers life-saving therapy to patients with
advanced chronic kidney disease (CKD). Unfortunately, access
to haemodialysis is limited by cost, availability and reliable
vascular access.
1
Optimal management of this limited resource is
therefore of key importance in reducing the high burden placed
on the healthcare system.
2-4
Currently, vascular access options are limited to an autogenous
arteriovenous fistula (AVF), a prosthetic arteriovenous graft
(AVG) and a central venous catheter (CVC). It is well established
that the autogenous AVF is superior to the other modalities in
terms of patency rates and infection risk. This is reflected in
local and international guidelines where it is recommended as the
primary option for all patients on haemodialysis.
5-7
The Fistula
First Breakthrough Initiative and the Kidney Disease Outcomes
Quality Initiative (KDOQI) guidelines in 2006 set in motion a
drive to create more AVFs and limit the use of CVCs.
7
This saw a
change in practice in high-income countries as more fistulae were
created and fewer AVGs and CVCs were used.
6
Access complications contribute to ineffective dialysis and
interruptions in treatment, which further contribute to the cost
of care. Significant problems with AVFs include non-maturation
and early thrombosis. Some studies have shown an early failure
rate as high as 46%.
6
If no suitable vessels are available, or when
all vessels in the arm are exhausted, a prosthetic AVG can be
placed.
8
The risk of infection is increased for an AVG compared
to an autogenous AVF but primary patency may be higher.
7
The most common problem with an AVG is stenosis due to an
abnormal turbulent flow pattern, which causes focal shear stress
in the native blood vessel and neo-intimal hyperplasia, which
ultimately leads to narrowing and thrombosis of the graft.
9
CVCs are the least-preferred modality and not recommended
for permanent access.
5
They have a high infection risk and also
cause permanent damage to the native vessels, which can lead
to central venous stenosis and occlusion, eventually limiting
future access modalities. They do have some benefits however,
since they can reliably be used as soon as they are placed when
urgent dialysis is required. CVCs also cause less haemodynamic
change and no increase in blood flow to the heart, which may be
important in patients with congestive cardiac failure.
10
The choice of vascular access shouldbe individualised according
to the specific patient characteristics. The primary goal should be
a distal autogenous AVF in the non-dominant arm, created three
to six months prior to the expected start of haemodialysis.
5,6
This
would allow time for maturation and even intervention in the
event the fistula fails to mature adequately, which will decrease
the need for CVC use. A recent study suggested that the benefit of
an autogenous fistula is lost when a patient is started on a CVC
and then has an AVF created.
11
The use of CVCs, even for a short
period, should be discouraged. This practice relies on the timeous
identification and referral of patients with CKD.
Reports from middle- and low-income countries show a
common theme: a high rate of AVF creation but typically only
Department of Vascular Surgery, Livingstone Tertiary
Hospital; Walter Sisulu University, Port Elizabeth, South
Africa
Ian R Grant, MB ChB, FCS (SA),
ianroygrant@gmail.comEduard J Honiball, MB ChB, MMed, FCS (SA), Cert Vasc Surg (SA)
Bhekifa Dube, MB ChB, FCS (SA), Cert Vasc Surg (SA), MPhil
Vasc Surg
Division Nephrology, Department of Medicine, Livingstone
Tertiary Hospital, Port Elizabeth; Division Nephrology and
Hypertension, Department of Medicine, University of Cape
Town, Cape Town, South Africa
Robert J Freercks, MB ChB, FCP (SA), Cert Neph, MPhil, FRCP
(Lon)