E CHUNG1,2, J SUN1, D KNAGGE1, S MCGINN1, C FISHER1
1Royal North Shore Hospital, St Leonards, Australia, 2Northern Sydney Clinical School, Sydney, Australia
Aim: To assess the impact of nephrologist referral patterns and events accelerating decline in estimated glomerular filtration rate (eGFR) on timely arteriovenous fistula (AVF) creation at a tertiary renal unit.
Background: Whilst it is recognised that individual nephrologists and acute causes of eGFR decline may contribute to untimely AVF creation, they have not been well-studied in existing literature.
Methods: We retrospectively reviewed incident patients requiring haemodialysis or had AVF creation at a single tertiary hospital from 2011 to 2016. Data was extracted from electronic medical records and the hospital vascular access coordinator database for the duration from referral to AVF creation and haemodialysis start, eGFR at surgical referral, referring nephrologist, and events accelerating eGFR decline (acute illness, surgery, nephrotoxin, transfer from other hospital, failed peritoneal dialysis or failed renal transplant). We used multinomial logistic regression to characterise the association between nephrologist (internal versus external to our unit) or events accelerating eGFR decline and the likelihood of functional AVF at haemodialysis start.
Results: Events accelerating eGFR decline, mostly hospitalisation for cardiovascular events or infections, were associated with an increased risk of haemodialysis start without a functional AVF (risk ratio [RR] 4.21, 95% confidence interval [CI] 1.96-9.03, p<0.0001). Referring nephrologists external to our renal unit may be associated with non-functional AVF at haemodialysis start (RR 6.60, 95% CI 1.74-25.13, p=0.006).
Conclusions: Events accelerating eGFR decline and referring nephrologists external to our renal unit were associated with an increased risk of starting haemodialysis without a functional AVF. A standardised referral protocol is needed but relying on an eGFR threshold for referral is challenging due to the unpredictable nature of events accelerating eGFR decline.
Edmund Chung is a 3rd year renal advanced trainee with an interest in glomerular diseases. He has completed his Bachelor of Medical Studies and Doctor of Medicine at the University of New South Wales in 2013 and a Master of Clinical Epidemiology at University of Sydney in 2015, and has subsequently published systematic reviews with the Cochrane Kidney and Transplant Group. He aspires to better underlying disease mechanisms in autoimmune glomerular diseases, identify novel therapeutic strategies, and translate them into clinical care.