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Kidney Care
Better Kidney Care for All
Vascular AccessAudit Report 2012
UK Renal Registry and NHS Kidney Care
Dr Richard FluckMr David Pitcher
Mrs Retha Steenkamp
03
CONTE
NTS
Contents
1 Foreword................................................................................................................
2 Acknowledgements ..............................................................................................
3 Executive summary ...............................................................................................
4 Introduction ...........................................................................................................
5 Methodology .........................................................................................................
6 Background data ...................................................................................................
7 Demographics........................................................................................................
7.1 Age and gender.....................................................................................................
7.2 Social deprivation ..................................................................................................
8 Referral times ........................................................................................................
9 Access at dialysis ...................................................................................................
9.1 Type of access at first dialysis................................................................................
9.2 Type of access after three months........................................................................
9.3 Comparison of access at first dialysis and after three months ...........................
10 Determinants of access – organisational factors ................................................
10.1 Referral to a surgeon ............................................................................................
10.2 Referral times and access at first dialysis .............................................................
10.3 Deprivation and access at first dialysis .................................................................
11 Access in prevalent HD patients on 31/12/2011 .................................................
12 Discussion ..............................................................................................................
13 Recommendations.................................................................................................
13.1 Data collection.......................................................................................................
13.2 Access provision .....................................................................................................
14 References..............................................................................................................
Appendix 1 – 2011 Data submission proforma ...................................................
Appendix 2 – Results reported by centres, by renal network............................
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04
1. Foreword
This is the second time that the kidney community in
England has been asked about the types of vascular
access used by patients receiving haemodialysis. There
is clearly still work to do, but it is evidence of just how
committed kidney units are to their patients’ vascular
access that so many centres have responded again this
time.
The first report contained data from the first six
months of 2010. This report is more ambitious and
contains data on all patients who started on dialysis
during 2011. It sets the foundations for a regular
collection of vascular access to allow continuous audit
of patients in the future.
The timely creation of definitive dialysis access is a
matter of careful judgement. The progressive decrease
year-on-year of patients who present late requiring
dialysis, coupled with the recent introduction of patient
decision aids to support shared decision making,
should improve experience and outcomes for patients
and help clinicians in planning a timely dialysis start.
This report was collected using a spreadsheet rather
than automated direct electronic capture, to which
many units responded by asking “why can this not be
done by direct electronic extraction?” So that’s the
plan from now on - it will be part of the general return
of information to the UK Renal Registry.
We may not have solved the issue of vascular access
for our patients, but the likelihood of dialysing with an
AV fistula or graft has increased to 77.6% in the
centres which submitted data in both audits (2005 and
2011data).
Some regions are doing better than others, so we need
to ask ourselves what and how can we learn from our
colleagues? Improving on a national figure of only
43% of patients starting haemodialysis via an AVF and
AVG needs to be reviewed by each and every kidney
team in the country.
I congratulate all those involved in this important audit
and thank them for their efforts, particularly staff at
the UK Renal Registry and NHS Kidney Care. Is there
scope to improve? Yes – there is. Will we achieve
improvement? Yes - we are now measuring access for
dialysis and we will remain focused on patient choice,
and then support patients to achieve their goals, be
that dialysis requiring timely formation access,
conservative kidney care, or pre-emptive renal
transplantation.
Donal O’Donoghue
National clinical director for kidney care
Department of Health
05
2. Acknowledgements
FORE
WORD
AND
ACKNOW
LEDGMEN
TS
We would like to thank all the staff in the 45 units who
submitted data on behalf of their patients and units.
We would also like to thank James Medcalf, clinical
lead for NHS Kidney Care, for editorial comments and
the following UK Renal Registry staff for their help: Sue
Shaw for project management; Fiona Braddon for
clinical informatics expertise and data processing; Ron
Cullen and Damian Fogarty for editorial comments and
management of UKRR input into this project.
06
3. Executive summary
There was some evidence of a change in the•
provision of vascular access for patients commencing
haemodialysis in 2011 with definitive access at
42.9% compared to 41% reported in the Kidney
Care Vascular Access Audit, covering patients starting
dialysis in 2010.
45 out of 63 renal centres in England, Wales and•
Northern Ireland took part in the audit, submitting
records on 3,236 patients.
Overall data completeness was good ranging from•
70% for surgical assessment at 3 months or more
prior to commencement of dialysis to 100% for other
data items.
The median age of patients was 67 years and 64 per•
cent of patients were male.
At first dialysis, 42.9% started with an arteriovenous•
fistula or graft, 21.3% with a non tunnelled line and
35.8% with a tunnelled line. There was variation
across renal networks.
After three months, 36% were dialysing via an•
arteriovenous fistula and 40% of patients were
receiving haemodialysis via a tunnelled catheter.
There was a proportional increase in deprivation from•
quintile 1 to 5 and 30% of individuals were in the
most deprived group (quintile 5).
In the majority of renal networks, late referral (less•
than 90 days from seeing a renal physician to dialysis)
accounted for 30% or less of haemodialysis starters.
Significant variation between centres was identified•
in the funnel plot showing the percentage of patients
with late referral by centre size.
A lower proportion of patients that were referred late•
(less than 90 days from seeing a renal physician to
dialysis) started dialysis with definitive access.
Only 5% of late referrals were referred to a surgeon•
compared to 30% of those referred between 90 and
365 days and 46% for patients referred more than a
year before starting dialysis.
Where patients were referred to a surgeon, 75%•
commenced with an arteriovenous fistula.
40% of patients still commenced dialysis with a•
venous catheter when they had been seen for a year
or more within a renal service.
Deprivation appeared to have no effect on access•
type.
The percentage of prevalent HD patients with•
definitive access increased by 6.9% from 70.7% in
2005 to 77.6% in 2011. All centres (except three)
that reported data for both years recorded an
increase in the percentage of HD patients with
definitive access in 2011 compared to 2005 (range
0.4 to 29.9).
07
4. Introduction
Vascular access for haemodialysis (HD) patients
continues to be an important area of risk. Evidence of
variation in provision between centres continues, with
the recent Kidney Care Vascular Access Audit reporting
outcomes for incident haemodialysis patients [1]. This
report highlighted that 59% of HD starters used a
venous catheter as their first access. It also confirmed
that at three months, there had been little
improvement in the access pattern.
EXEC
UTIVE SU
MMER
YAND IN
TRODUCTION
08
5. Methodology
The Vascular Access Audit, managed by The UK Renal
Registry (UKRR), collected vascular access data for 2011 as
a continuation of the National Kidney Care Audit (Vascular
Access for 2009 and 2010 data) which was managed by
the NHS Information Centre in 2010 and 2011.
The data collected for the Dialysis Access Audit 2012 was
based upon the data items already collected within the
National Kidney Care Audit Vascular Access Report 2011
[1] and covered all patients commencing dialysis in 2011.
At year end 2011, all renal centres in England, Wales and
Northern Ireland were asked to complete an excel
spreadsheet (appendix 1) which was submitted directly to
the UKRR using secure data transfer procedures. In
contrast to the prior audits, all new patients commencing
dialysis for the first time during the whole of 2011 were
the intended participants. These data items cover basic
patient demographic information and specific facts about
the patient’s treatment, which included:
the type of access used at first dialysis •
the date of the patient’s first dialysis session •
the date the patient was first seen by a renal physician •
the access type in use three months following the•
patient’s first dialysis session
whether the patient was referred to a surgeon at least•
three months before the patient’s first dialysis session.
Upon receipt of the data each file was checked to ensure
that the expected patient numbers based on previous years
take-on figures were in line with actual numbers received.
The records collected by the questionnaires were matched
with the UK Renal Registry database allowing identification
of unreported deaths within three months of commencing
dialysis and patients who had previously received RRT.
During validation of the data, 281 records were excluded
(144 for being duplicates, and 137 for failing to match the
inclusion criteria of commencing dialysis for the first time
during 2011). After validation there remained 4,099
records for patients starting on either haemodialysis or
peritoneal dialysis. The 863 patients who commenced RRT
on peritoneal dialysis were excluded from this analysis of
vascular access unless stated otherwise.
Referral time was defined as the time between the date of
first being seen by a renal physician and the date of
commencing dialysis. A valid referral time was calculated
for a patient if they had both dates recorded and if the
date of first being seen by a renal physician was no later
than the date of commencing dialysis. Two centres had no
valid referral times calculated for any of their patients due
to poor data completion.
If a patient did not have the date that they were first seen
by a renal physician available, then the data field should
have been left blank. However, patients from London St
Barts & The London Hospital for whom this date was
unavailable had had this date recorded as the date they
started dialysis. For this reason, when the data were
validated, all 96 patients from London St Barts & The
London Hospital who had matching dates for these two
data fields had the date that they were first seen by a renal
physician set to missing. This might have caused an under
estimation of the number of late referrals at London St
Barts & The London Hospital as some dates that were
changed might have been accurate.
A total of 45 centres returned information on
incident patients commencing haemodialysis. There
were a total of 3,236 individual cases. Renal centres
reported on a range of between 12 and 214 patients
(table 1). Results are not presented by centre
routinely in the main part of this report, but are
available in appendix 2 of this report for reference.
The completeness of patients reported on by centre
who commenced HD in 2011 was evaluated against
the 2010 incident numbers [2]. There was a small
decrease (1.8%) in the number of HD patients
commencing HD in 2011 in the 45 centres that
returned vascular access data to the UK Renal
Registry compared to the 2010 incident numbers for
these same centres. Although there might well be
under-reporting of patients for some centres, the
total number of patients reported to have started on
HD in 2011 (3,236) seems reasonable compared to
previous years.
09
6. Background data
Centre name Number
Antrim Hospital 19
Bangor- Gwynedd Hospital 15
Belfast City Hospital 81
Birmingham - Heartlands Hospital 89
Birmingham - Queen Elizabeth Hospital 163
Bradford - St Luke's Hospital 40
Brighton - Royal Sussex County Hospital 82
Bristol - Southmead Hospital 96
Cardiff - University Hospital of Wales 139
Chelmsford - Broomfield Hospital 30
Clwyd - Glan Clwyd Hospital 12
Colchester General Hospital 43
Derby - Royal Derby Hospital 36
Doncaster Royal Infirmary 31
Dudley - Russells Hall Hospital 16
Exeter - Royal Devon and Exeter Hospital 127
Gloucester Royal Hospital 42
Hull Royal Infirmary 59
Kent and Canterbury Hospital 94
Leeds - St James's University Hospital and Leeds GeneralInfirmary
119
Leicester General Hospital 181
Liverpool - University Hospital Aintree 56
London - Royal Free Hospital 127
London - St Barts and The London Hospital 214
London - St Helier Hospital, Carshalton 139
Manchester - Hope Hospital 91
Middlesbrough - James Cook University Hospital 73
Newcastle - Freeman Hospital and Royal Victoria Infirmary 68
Newry - Daisy Hill Hospital 27
Nottingham City Hospital 71
Oxford Radcliffe Hospital 99
Plymouth - Derriford Hospital 24
Portsmouth - Queen Alexandra Hospital 148
Preston - Royal Preston Hospital 104
Sheffield - Northern General Hospital 105
Southend Hospital 18
Stevenage - Lister Hospital 30
Stoke - University Hospital of North Staffordshire 53
Sunderland Royal Hospital 43
Swansea - Morriston Hospital 90
Truro - Royal Cornwall Hospital 23
Tyrone County Hospital 14
Wolverhampton - New Cross Hospital 56
Wrexham Maelor Hospital 16
York District General Hospital 33
Total 3,236
Table 1. Patient records by participating centre
MET
HODOLO
GY A
ND
BACKGRO
UND D
ATA
Overall data completeness was good (table 2). Access at first
dialysis, date of first dialysis, gender and postcode had a 98%
to 100% data return. NHS number was returned in 92% of
cases and the access in use at 3 months in 85% of cases. Only
70% completed the record for surgical assessment at 3
months or more prior to commencement of dialysis.
10
Data field Number of records completed Percentage of records completed
NHS number 2,984 92.2
Access at first dialysis 3,186 98.5
Access at 3 months 2,737 84.6
Date first seen by physiciana 2,986 92.3
Date of first dialysis 3,235 99.9
Assessed by surgeon 2,268 70.1
Gender 3,236 100.0
Postcode 3,218 99.4
Table 2. Data completeness for the 3,236 patient records submitted
a Date first seen by a physician was set to missing for some patients at London St Barts as outlined in the methodology
11
7. Demographics
900
800
700
600
500
400
300
200
100
0
16-24 25-39 40-54 55-64 65-79 80+
Age Group
Num
ber o
f pat
ient
s
Female
Male
7.1 Age and genderThere was a predominance of male patients in the sample
size (male n=2,074, female n=1,162) (figure 1).The peak
age range for incident patients was between 65 and 79
for both males and females. The median age by renal
centre ranged from 60 to 77 (figure 2).
Figure 1. Age and gender of patients submitted to audit
DEM
OGRA
PHICS
12
Southend Hospital
Gloucester Royal Hospital
Hull Royal In!rmary
Swansea - Morriston Hospital
Stoke - University Hospital of North Sta"ordshire
Liverpool - University Hospital Aintree
Nottingham City Hospital
Brighton - Royal Sussex County Hospital
Oxford Radcli"e Hospital
Bristol - Southmead Hospital
wolverhampton - New Cross Hospital
Antrim Hospital
Doncaster Royal In!rmary
Birmingham - Heartlands Hospital
Exeter - Royal Devon and Exeter Hospital
Tyrone County Hospital
She#eld - Northern General Hospital
Bangor - Gwynedd Hospital
London - St Helier Hospital, Carshalton
Colchester General Hospital
Derby - Royal Derby Hospital
Plymouth - Derriford Hospital
Cardi" - University Hospital of Wales
Clwyd - Glan Clwyd Hospital
Kent and Canterbury Hospital
Dudley - Russells Hal Hospital
Sunderland Royal Hospital
Leeds - St James’s University Hospital and Leeds General In!rmary
Stevenage - Lister Hospital
Manchester - Hope Hospital
Portsmouth - Queen Alexandra Hospital
Birmingham - Queen Elizabeth Hospital
Leicester General Hospital
York District General Hospital
Newcastle - Freeman Hospital and Royal Victoria In!rmary
Belfast City Hospital
Chelmsford - Broom!eld Hospital
Middlesborough - James Cook University Hospital
Truro - Royal Cornwall Hospital
Wrexham Maelor Hospital
Bradford - St Luke’s Hospital
London - Royal Free Hospital
Preston - Royal Preston Hospital
Newry - Daisy Hill Hospital
London - St Bart’s and The London Hospital
Median age of patients at !rst dialysis
50 55 60 65 70 75 80
Figure 2. Median age of HD patients at first dialysis by renal centre
13
35
30
25
20
15
10
5
0Perc
enta
ge
Quintile
1 - Least deprived
2
3
4
5 - Most deprived
7.2 Social deprivationThere was a proportional increase in deprivation from
quintile 1 to 5 (5 being the most deprived) and 30% of
individuals were in quintile 5 (figure 3).
Figure 3. Deprivation quintile profile for HD patients resident in England Note: Based on 2,745 patient records (patients resident in England with a valid postcode)
The deprivation quintiles were calculated using the
English Indices of Deprivation 2010 which measured
relative levels of deprivation in small areas of England
called Lower Layer Super Output Areas [3]. These 32,482
areas were ranked from least deprived to most deprived
and then split into equal quintiles. The patient records
were matched to an area, and accordingly a deprivation
quintile, by postcode. Only patients resident in England
with a valid postcode were included in the analyses
involving deprivation quintiles.
DEM
OGRA
PHICS
14
Perc
enta
ge
Network (England only)
1 - Least deprived
2
3
4
5 - Most deprived
45
40
35
30
25
20
15
10
5
0Cheshire& Merseyside(54)
Cumbria &Lancashire(90)
East Midlands(283)
East of England(94)
GreaterManchester(91)
London(472)
North East(183)
South Central(245)
South EastCoast(306)
South West(175)
WestMidlands(371)
Yorkshire &the Humber(380)
Figure 4. Deprivation quintile profile for HD patients resident in England by renal centre attendedNote: Number of patients at each network listed in brackets
Deprivation by renal network is shown in figure 4.
Cheshire and Merseyside, London, the North East and the
West Midlands had the greatest level of deprivation with
greater than 40% of patients in the most deprived
category. In contrast, in the East Midlands, East of
England, South Central, South East Coast and South West
the distribution was either flat or tended to be
less deprived.
15
100
90
80
70
60
50
40
30
20
10
0
Ches
hire
& M
erse
ysid
e 0
(56)
Cum
bria
& L
anca
shire
104
(0)
East
Mid
land
s 27
9 (9
)
East
of E
ngla
nd 1
11 (1
0)
Gre
ater
Man
ches
ter 8
3 (8
)
Lond
on 3
82 (9
8)
Nor
th E
ast 1
84 (0
)
Sout
h Ce
ntra
l 238
(9)
Sout
h Ea
st C
oast
175
(0)
Sout
h W
est 2
81 (3
1)
Wes
t Mid
land
s 30
4 (7
3)
York
shire
& th
e H
umbe
r 385
(2)
Engl
and
2527
(296
)
Nor
ther
n Ire
land
136
(5)
Wal
es 2
64 (8
)
UK
2927
(309
)
Perc
enta
ge
>1 year
90 days to 1 year
<90 days
Network (England only) Nation UK
8. Referral times
Referral interval from time of first consultation with a
renal physician to the time of first dialysis could be
assessed in 3,023 available records.
Figure 5 provides referral time banded in three
categories - less than 90 days; 90 days to one year; and
greater than one year. In the majority of renal
networks, late referral contributed 30% or less of
haemodialysis starters. There were no under 90 day
starters in the Greater Manchester area but the sample
size was small from that region.
Figure 5. Referral time from physician to first dialysis by renal networkNote: Number of patients with data returned by network name (number with missing data in brackets)
REFE
RRAL TIMES
16
Figure 6 shows the number of patients with late referral to
HD (<90 days) by number of patients per renal centre. As
can be expected there is a strong correlation between the
numbers of patients referred late and overall patient
numbers by centre. A funnel plot was used to identify
significant centre variation (figure 7).
Num
ber o
f pat
ient
s w
here
refe
rral
per
iod
from
phy
sici
anto
!rs
t hae
mod
ialy
sis
is <
90 d
ays
Number of patients with data per renal centre
70
60
50
40
30
20
10
0
0 4020 60 80 100 120 140 160 180 200
Figure 6. Number of patients with late referral to haemodialysis (<90 days), by number of patients perrenal centreNote: Total patients per renal centre do not include patients who do not have a valid value for referral time. Twocentres have been excluded as they do not have any patients with a valid referral time
17
0 4020 60 80 100 120 140 160 180 20
60
50
40
30
20
10
0
Perc
enta
ge w
ith re
ferr
al <
90da
ys
Number of patients in centre
Solid lines show 95% limitsDotted lines show 99.9% limits
For any number of patients in the cohort (x-axis) one can
identify whether the percentage of patients referred
within < 90 days (y-axis) falls within, plus or minus two
standard deviations (SDs) from the national mean (solid
lines, 95% limits) or three SDs (dotted lines, 99.9%
limits). With 45 centres included in the analysis, it would
be expected by chance that two centres would fall
outside the 95% (1 in 20) confidence limits. The results
have to be cautiously interpreted due to the extent and
variation in missing data, small numbers of patients in
some centres and non-adjustment for any patient related
factors. For these reasons outlying centres were not
identified in this report but as the vascular access data
collection and quality improves, outlying centres will in
future be identified and reported on.
The funnel plot (figure 7) identifies significant outliers by
centre. Three centres had a significantly higher than
average percentage of late referrals (referral <90 days
before start of HD) and were outside the 95% limits,
with one centre above the 99% limit. The four centres
with a higher than average percentage of patients
referred late had a relatively high proportion of patients
where the date of starting HD and the date of referral to
a physician were the same. Four centres had a
significantly lower than average proportion of late
referred patients and were outside the 95% limits. Two
centres had no patients reported as referred < 90 days
and one centre had a significantly lower than average
proportion of late referred patients and were below the
99% limits.
Figure 7. Funnel plot showing the percentage of patients with late referral by centre size
REFE
RRAL TIMES
18
9. Access at dialysis
9.1 Type of access at first dialysis For the cohort of incident patients, 41.0% commenced
with an arteriovenous fistula, 21.3% with a non tunnelled
line and 35.8% with a tunnelled line (figure 8).
Arteriovenous �stula (1,313)
Arteriovenous graft (51)
Non-tunnelled line (680)
Tunelled line (1,142)
41%
2%21%
36%
Figure 8. Access at first dialysis
19
Arteriovenous �stula
Arteriovenous graft
Tunnelled line
Non-tunnelled line
Cheshire and Merseyside
Cumbria and Lancashire
East Midlands
East of England
Greater Manchester
London
North East
South Central
South East Coast
South West
West Midlands
Yorkshire and the Humber
Northern Ireland
Wales
0 20 40 60 80 100
Percentage
There was variation across renal networks (figure 9).
Cheshire and Merseyside only reported on 55 patients
but more than 90% of them started with an
arteriovenous fistula. Similarly, Greater Manchester
reported 91 cases of which two thirds commenced with
an arteriovenous fistula. Northern Ireland and London
reported the lowest rates of arteriovenous fistula usage
(less than 30% in both regions) and performance across
other networks had a range from 33-52% starting HD
with an arteriovenous fistula. There was little difference
between access at first haemodialysis in those centres
that reported significant incident PD patient usage.
Figure 9. Access at first dialysis, by renal network for haemodialysis patientsACCES
S AT DIALY
SIS
20
Figure 10 shows data were missing for 15% (499) of
patients at three months and a further 5% (175) of
patients died before three months. Another two
patients withdrew or recovered function and five were
transplanted.
Forty per cent (1,283) of patients were still receiving
haemodialysis via a tunnelled catheter. Thirty-six per
cent (1,167) were dialysing via an arteriovenous fistula
and 2% (54) of patients had changed modality to
peritoneal dialysis.
Missing (499)
Arteriovenous !stula (1,167)
Arteriovenous graft (34)
Death before 3 months (175)
Non-tunnelled line (17)
PD catheter (54)
Patient withdrew from dialysis (1)
Recovered function (1)
Transplanted (5)
Tunnelled line (1,283)
15%
36%
40%
1%1%
5%
2%
0%
0%0%
Figure 10. Access or outcome at three months for all patients who started on haemodialysis
9.2 Type of access after three months
21
Cheshire and Merseyside
Cumbria and Lancashire
East Midlands
East of England
Greater Manchester
London
North East
South Central
South East Coast
South West
West Midlands
Yorkshire and the Humber
Northern Ireland
Wales
0 20 40 60 80 100
Percentage
Arteriovenous !stula
Arteriovenous graft
Tunnelled Line
Non-tunnelled line
PD catheter
Died
Transplanted
Withdrew
Recovered
Missing
Patterns of access usage at three months by renal
network did not show any significant difference from
the incident data (figure 11). The lowest use of
arteriovenous fistulas was demonstrated in London, the
South West and Northern Ireland, and the highest rates
in Greater Manchester, East Midlands, Cumbria and
Lancashire and Wales.
Figure 11. Access or outcome at three months for all patients who started on haemodialysis
ACCES
S AT DIALY
SIS
22
Tables 3, 4 and 5 document first dialysis access and three
month dialysis outcome. These data include those
patients who commenced dialysis on peritoneal dialysis
allowing a more complete overview of how patients
switched between modalities. An analysis focusing solely
on patients commencing on peritoneal dialysis will be
covered in an additional report.
Table 3 provides the comparison of access in use at first
dialysis and at three months for all patients. Fifty-four
patients switched modality to peritoneal dialysis. All but
one of those patients had commenced dialysis on a
venous catheter. The majority of patients who
commenced with a venous catheter continued dialysis
with a venous catheter, although most were using
tunnelled access. Less than 6% of patients who
commenced dialysis with an arteriovenous fistula had
switched to a venous catheter and there was little
evidence of technique failure for those patients who
commenced with an arteriovenous graft. Of the 185
patients who died before three months, 134 of those
patients had commenced dialysis via venous catheters.
Access at firstdialysis
Access at 3 months
Arteriovenousfistula
Arteriovenousgraft
Tunnelledline
Non-tunnelledline
PD catheter
Deathbefore 3months
Transplanted Withdrew Recovered Missing Total
Arteriovenousfistula
994 5 74 1 1 31 2 0 0 205 1,313
Arteriovenousgraft
3 23 0 0 0 1 0 0 0 24 51
Tunnelled line 110 3 826 5 27 66 3 1 0 101 1,142
Non-tunnelledline
59 3 382 11 26 68 0 0 1 130 680
PD catheter 7 0 42 0 682 10 0 0 0 122 863
Missing 1 0 1 0 0 9 0 0 0 39 50
Grand total 1,174 34 1,325 17 736 185 5 1 1 621 4,099
Table 3. Comparison of access at first dialysis and after three months for all patients (HD, PD, unknowndialysis type at first dialysis)
9.3 Comparison of access at first dialysis and after three months
23
Table 4 gives details of access at first dialysis and at 3
months, for those patients who were referred late (defined
as the referral from physician to dialysis interval as less than
90 days). At the point of dialysis commencement, only 27
patients were dialysing via an arteriovenous fistula or graft.
703 patients commenced with tunnelled or non-tunnelled
access. After three months, 31 of these patients had
continued on haemodialysis but moved to an arteriovenous
fistula (n=30) or an arteriovenous graft (n=1), 18 had
switched to peritoneal dialysis, and 65 had died.
Access at firstdialysis
Access at 3 months
Arteriovenousfistula
Arteriovenousgraft
Tunnelledline
Non-tunnelledline
PD catheter
Deathbefore 3months
Transplanted Withdrew Recovered Missing Total
Arteriovenousfistula
15 0 5 0 0 0 0 0 0 4 24
Arteriovenousgraft
0 2 0 0 0 0 0 0 0 1 3
Tunnelled line 15 0 285 0 8 23 0 0 0 60 391
Non-tunnelledline
15 1 196 5 10 42 0 0 0 43 312
PD catheter 0 0 2 0 61 0 0 0 0 106 169
Missing 0 0 1 0 0 7 0 0 0 26 34
Grand total 45 3 489 5 79 72 0 0 0 240 933
Table 4. Comparison of access at first dialysis and after three months for all patients, where referral fromphysician to dialysis was less than 90 days (HD, PD, unknown dialysis type at first dialysis)
ACCES
S AT DIALY
SIS
24
Access at firstdialysis
Access at 3 months
Arteriovenousfistula
Arteriovenousgraft
Tunnelledline
Non-tunnelledline
PD catheter
Deathbefore 3months
Transplanted Withdrew Recovered Missing Total
Arteriovenousfistula
940 5 68 1 1 31 2 0 0 141 1,189
Arteriovenousgraft
3 21 0 0 0 1 0 0 0 19 44
Tunnelled line 93 3 493 5 16 39 3 1 0 60 713
Non-tunnelledline
44 2 166 5 16 19 0 0 1 43 296
PD catheter 6 0 35 0 590 9 0 0 0 106 746
Missing 1 0 0 0 0 2 0 0 0 12 15
Grand total 1,087 31 762 11 623 101 5 1 1 381 3,003
Table 5. Comparison of access at first dialysis and after three months for all patients, where referral fromphysician to dialysis was more than 90 days
Table 5 shows access at first dialysis and at three months
for those patients in whom the referral interval was timely
(defined as the referral from physician to dialysis interval as
greater than 90 days). For these patients, 1,233
commenced with an arteriovenous fistula or arteriovenous
graft and 1,009 commenced with a tunnelled or
non-tunnelled catheter. After three months, 32 of the
patients commencing on a venous catheter had switched to
peritoneal dialysis and 58 had died. Thirty-one patients
commencing dialysis with an arteriovenous fistula died prior
to three months. Of the 1,189 patients commencing with
an arteriovenous fistula, 69 patients had had access failure
and were dialysing using venous catheters. In comparison,
of the 1,009 patients who commenced dialysis with venous
catheters, 137 had successfully switched to an
arteriovenous fistula and five to an arteriovenous graft.
25
10. Determinants of access – organisational factors
10.1 Referral to a surgeon
Yes
No
Cheshire and Merseyside
Cumbria and Lancashire
East Midlands
East of England
Greater Manchester
London
North East
South Central
South East Coast
South West
West Midlands
Yorkshire and the Humber
Northern Ireland
Wales
UK
0 20 40 60 80 100
Percentage
56 (100%)
104 (0%)
288 (13%)
121 (36%)
91 (100%)
480 (59%)
184 (40%)
247 (2%)
176 (2%)
312 (45%)
377 (0%)
387 (48%)
141 (1%)
272 (19%)
3,236 (30%)
Figure 12. Percentage of HD patients assessed by a surgeon at least three months before starting dialysis, byrenal networkNote: Number of patients in each network listed after name (% missing in brackets)
For those patients commencing haemodialysis in a
planned timely way, data were requested on whether they
had been assessed by a surgeon at least three months
before commencement of dialysis. Data were not returned
in 968 cases but of the remaining cohort, 1,029 incident
haemodialysis patients had been seen by a surgeon and
1,239 had not.
There was wide variation by network but these data need
to be interpreted with caution due to the extent of, and
variation in, missing data and small number reporting
(figure 12). Most networks reported between 40% and
60% of patients having been assessed by a surgeon. The
exceptions were London, where the reported value was
less than 10%, the South East Coast (34.7%) and Wales
which exceeded 60%.
DET
ERMINANTS
OF
ACCES
S
Figure 13 shows the percentage of HD patients assessed
by a surgeon at least three months before starting dialysis
by referral interval (defined as the referral from physician
to dialysis interval). The probability of surgical referral
increased based on the time between first physician
consultation and first dialysis. For those referred less than
90 days before start of dialysis, less than 5% of patients
had seen a surgeon. Of those patients commencing
between 90 and 365 days, referral rate to a surgeon was
less than 30% and for those greater than a year still a
minority (46%) had undergone surgical assessment.
If a patient had seen a surgeon three months before
starting dialysis, the probability of them commencing on
an arteriovenous fistula or graft was considerably higher
than if they had not (figure 14). Interestingly, 10% of
patients had commenced dialysis from an arteriovenous
fistula despite lack of surgical assessment. For those who
had seen a surgeon, 75% commenced with an
arteriovenous fistula.
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge
Number of days between physician visit and !rst dialysis
Missing
No
Yes
No Data(309 patients)
<90 days(670 patients)
90 days to 1 year(421 patients)
>1 year(1,836 patients)
Figure 13. Referral to surgeon, by referral period
26
10.2 Referral times and access at first dialysis
100
90
80
70
60
50
40
30
20
10
0Perc
enta
ge
Surgeon referral
Non-tunnelled line
Tunnelled line
Arteriovenous graft
Arteriovenous !stula
Yes(1,029 patients)
No(1,201 patients)
Missing(956 patients)
Figure 14. Type of access at first dialysis for HD patients, by whether a patient was assessed by a surgeonat least three months before starting dialysisNote: Results based on 3,186 records (excludes 50 records with missing access at first dialysis)
27
DET
ERMINANTS
OF
ACCES
S
100
90
80
70
60
50
40
30
20
10
0Perc
enta
ge
Referral time from physician to !rst dialysis
Non-tunnelled line
Tunnelled line
Arteriovenous graft
Arteriovenous !stula
<90 days(668 patients)
90 days to 1 year(417 patients)
>1 year(1,825 patients)
Overall, even for patients commencing dialysis having
been seen for a year or more within a renal service, 40%
still commenced with a venous catheter (figure 15). That
percentage was higher for the other referral groups, so
that for those patients known for greater than 90 but
less than 365 days, the probability of catheter usage at
the start of dialysis exceeded 65%.
Figure 15. Referral time from physician to first dialysis by access type, HD startersNote: 326 patients excluded for incomplete data (276 referral time, 50 access when starting dialysis)
28
29
Definitive and non-definitive access use at first dialysis
matched the deprivation pattern of the overall incident
population, suggesting no influence of deprivation on
access provision (figure 16).
Perc
enta
ge
Type of access
35
30
25
20
15
10
5
0
1 - Least deprived
2
3
4
5 - Most deprived
De!nitive Non De!nitive
Figure 16. Deprivation by definitive/not definitive access at first dialysisDefinitive = arteriovenous graft or fistulaNon definitive = non tunnelled line or tunnelled lineResults based on 2,702 records (patients resident in England with valid postcode and known access type at first dialysis)
10.3 Deprivation and access at first dialysis
DET
ERMINANTS
OF
ACCES
S
11. Access in prevalent HD patients on 31/12/2011
Table 6. Access in prevalent HD patients
Centre
Access in prevalent HD patients on 31/12/2011Access in prevalent HD patients on
31/03/2005a% change ofHD patients
withdefinitiveaccess from2005 - 2011
Number ofHD patients
% on HDwith AVF
% on HDwith AVG
% on HDwith a
catheter/ line
% on HDwith AVF
% on HDwith AVG
% on HDwith a
catheter/ line
Antrim Hospital - 88.5 0.0 11.5
Belfast City Hospital 224 49.3 0.0 50.7 46.6 2.3 51.1 0.4
Birmingham - Heartlands Hospital 452 85.2 2.4 12.4 69.2 4.9 26.0 13.6
Birmingham - Queen Elizabeth Hospital 899 72.6 1.9 25.5 70.5 2.5 27.0 1.5
Bradford - St Luke's Hospital 198 76.8 0.5 22.7 69.4 0.0 30.6 7.8
Brighton - Royal Sussex County Hospital 353 65.4 8.6 25.9 50.9 9.7 39.4 13.5
Bristol - Southmead Hospital 450 75.2 14.8 10.0 71.2 13.9 14.9 4.9
Cardiff - University Hospital of Wales 471 62.6 0.6 36.8 61.0 0.0 39.0 2.2
Chelmsford - Broomfield Hospital 140 69.1 0.0 30.9 59.8 7.2 33.0 2.1
Clwyd - Glan Clwyd Hospital 74 83.0 1.3 15.7 66.7 0.0 33.3 17.6
Colchester General Hospital 120 30.4 2.2 67.4
Derby - Royal Derby Hospital 216 83.6 6.0 10.4 74.2 0.5 25.3 14.8
Doncaster Royal Infirmary 158 74.7 7.6 17.7
Dudley - Russells Hall Hospital 153
Exeter - Royal Devon and Exeter Hospital 383 68.1 7.8 24.0
Gloucester Royal Hospital 194 58.2 0.0 41.8 79.5 5.5 15.0 -26.9
Kent and Canterbury Hospital 375 64.0 6.7 29.3
Leeds - St James's University Hospitaland Leeds General Infirmary
513 80.0 3.2 16.8 77.6 1.3 21.2 4.4
Leicester General Hospital 845 76.7 4.4 18.9 68.4 0.8 30.8 11.9
Liverpool - University Hospital Aintree 174 93.4 5.9 0.7 67.2 4.2 28.7 28.0
London - Royal Free Hospital 694 66.7 3.1 30.3
Manchester - Hope Hospital 557 62.6 2.5 34.9 65.7 1.6 32.7 -2.2
Middlesbrough - James Cook UniversityHospital
316 65.3 1.1 33.7 73.4 1.7 24.9 -8.8
Newcastle - Freeman Hospital and RoyalVictoria Infirmary
267 66.7 4.8 28.6 54.0 1.8 44.2 15.7
Newry - Daisy Hill Hospital 111 46.0 0.0 54.0
Nottingham City Hospital 398 82.7 7.4 9.9 52.1 8.1 39.7 29.9
Oxford Radcliffe Hospital 425 69.8 4.3 25.9 73.1 1.9 25.0 -0.9
Plymouth - Derriford Hospital 132 80.0 4.0 16.0 53.2 12.8 33.9 17.9
Portsmouth - Queen Alexandra Hospital 526 52.1 34.5 13.4
Preston - Royal Preston Hospital 521 83.1 1.7 15.2 74.3 2.0 23.8 8.6
Southend Hospital 120 80.8 2.5 16.7 77.4 0.0 22.6 5.9
Stoke - University Hospital of NorthStaffordshire
306 84.8 0.0 15.2
Truro - Royal Cornwall Hospital 149 83.0 3.0 14.0 74.3 2.7 23.0 9.0
Wrexham Maelor Hospital 89 81.0 8.0 11.0 58.3 13.1 28.6 17.6
York District General Hospital 135 78.0 2.0 20.0 69.8 6.0 24.1 4.1
a Data published by UK Renal Registry [4]Note: AVF=arteriovenous fistula, AVG=arteriovenous graft, definitive access=AVF or AVG in use
30
31
The majority of centres that returned data had a higher
percentage of prevalent HD patients with definitive
access in 2011 compared to 2005, although there is
wide between centre variation (table 6). Centres that did
not return data on prevalent patients in 2011 have been
excluded from the table. Ten centres reported an increase
of more than 10% in prevalent HD patients with
definitive access in 2011 compared to 2005 and of
these, two centres reported an increase of more than
20%. The percentage of prevalent HD patients with
definitive access in 2011 ranged from 33% to 99%. The
percentage of prevalent HD patients that had definitive
access increased from 70.7% in 2005 to 77.6% in 2011.
This is based on patients from 25 centres who
contributed data to both years.
Figure 17 shows the centre level range of percentages of
prevalent HD patients with non-definitive access. The
crosses represent the centre level means. A paired t-test
found there was a significant difference between the
means (p=0.0029). Data by access type and centre for
prevalent dialysis patients at 31/12/2011 are shown in
figure 18.
60
50
40
30
20
10
0Percen
tage
Year
2005 2011
+
+
Figure 17. Box and whisker plot showing the percentage of prevalent HD patients with non-definitiveaccess on 31/03/2005 and 31/12/2011Note: Based on 25 centres with prevalent data for 2005 (n=5,827) and 2011 (n=8,312)
ACCES
S IN PRE
VALE
NT
HD PATIEN
TS
Percentage
0 10 20 30 40 50 60 70 80 90 100
PD
AVF
AVG
Catheter/line
Colchester General Hospital (120)
Newry - Daisy Hill Hospital (123)
Belfast City Hospital (252)
Gloucester Royal Hospital (233)
Middlesborough - James Cook University Hospital (335)
Manchester - Hope Hospital (629)
Cardi! - Uiversity Hospital of Wales (575)
London - Royal Free Hospital (787)
Chelmsford - Broom"eld Hospital (172)
Kent and Canterbury Hospital (444)
Newcastle - Freeman Hospital and Royal Victoria In"rmary (318)
Birmingham - Queen Elizabeth Hospital (1,066)
Oxford Radcli!e Hospital (519)
Brighton - Royal Sussex County Hospital (436)
Exeter - Royal Devon and Exeter Hospital (462)
Bradford - St Luke’s Hospital (229)
York District General Hospital (161)
Leicester General Hospital (1,002)
Doncaster Royal In"rmary (185)
Southend Hospital (138)
Leeds - St James’s University Hospital and Leeds General In"rmary (605)
Preston - Royal Preston Hospital (586)
Clwyd - Glan Clwyd Hospital (95)
Stoke - University Hospital of North Sta!ordshire (387)
Truro - Royal Cornwall Hospital (176)
Plymouth - Derriford Hospital (181)
Portsmouth - Queen Alexandra Hospital (620)
Birmingham - Heartlands Hospital (498)
Wrexham Maelor Hospital (109)
Bristol - Southmead Hospital (522)
Nottingham City Hospital (491)
Derby - Royal Derby Hospital (327)
Liverpool - University Hospital Aintree (187)
Figure 18. Distribution of prevalent patients on 31/12/2011 by access type and centreNote: Twelve centres excluded for not returning complete prevalent data. Number of patients at each centre in brackets.AVF=arteriovenous fistula, AVG=arteriovenous graft
32
33
There is little evidence of change in the provision of
vascular access for patients commencing dialysis in 2011,
when compared to the findings of the Kidney Care
Vascular Access Audit, published in 2011 using a six
month cohort of patients from January to June 2010.
This audit used the same methodology as the prior work,
and allows some comparisons to be made.
One year is probably ambitious to expect systematic
changes to have occurred, but there are useful points to
be made from the new data.
First, data collection has been much less problematic.
Whilst there is a desire to move away from standalone
spreadsheet collection tools, data collection has run
quickly and with a high degree of completeness. Fewer
centres took part (45 compared to 60) but provided
incident data for 12 months and hence more cases.
Second, variation in provision by network and by centre is
still evident. The Renal Association standard sets a target
of 65% for patients to start haemodialysis with either a
fistula or a graft if they present more than 90 days before
the start of dialysis [5]. The overall figure of 43% starting
dialysis with a fistula or graft is almost identical to the
figure from the Kidney Care VA audit 2011. Fifty-five
percent of patients referred more than 90 days before
commencing HD started dialysis with a fistula or a graft
and again this is similar to the Kidney Care VA audit
2011 results.
It is interesting to see that when patients are referred to a
surgeon, the probability of starting with a fistula is much
higher. The low rate of referral to surgeons suggests
recognition or prediction of end stage renal failure still
remains an issue. As was discussed in last year’s
publication, more research is needed to determine how
the need for RRT is assessed and predicted. With the
publication of the IDEAL trial [6], an understanding of the
risks and benefits around dialysis initiation is needed.
Vascular access preparedness may be a factor in
determining whether to commence haemodialysis and
included in scoring criteria to assess a start point [7].
For those presenting at end stage in an unplanned way
(defined by no prepared vascular access) there is also the
issue of bridging to definitive access. Almost universally,
bridging has meant the use of a venous catheter. It is
encouraging to see a small proportion of people moving
to PD inside three months. The inclusion of PD in this
audit is important and PD may have an important role as
a bridge [8].
This idea of bridging and ‘unplanned starts’ needs
exploration. In terms of bridging techniques there are
options of venous catheters, PD catheters and holding off
dialysis initiation whilst access is prepared. The term
‘unplanned start’ covers those patients who arrived late
to the renal team (and that number is falling) and those
patients in the renal system for whom preparation has
not been started or completed. That latter group now
makes up the majority of patients who start
haemodialysis with a venous catheter.
From this audit, it can be seen that referral to an
appropriate vascular access surgeon is not made by
renal teams, despite apparent time to do so. This turns
the focus back on predicting when access planning
should commence. Only 46% of patients in renal clinics
for more than one year are referred to surgery, but of
those referred, 75% have access in place.
In summary, the recommendations from the 2011 Kidney
Care Vascular Access audit remain. In particular,
recommendations around data collection and access
provision require no revision.
12. Discussion
DISCUSS
ION
13. Recommendations
13.1 Data collection1. Data items relevant to the audit of vascular access in
haemodialysis should be reviewed with a view to
simplification. The key mandatory item should be
access type in use at each dialysis session.
2. Individual dialysis centres should review data
collection and extraction to the UK Renal Registry.
3. The UK Renal Registry should collect data on vascular
access and return data quality reports to centres prior
to analysis. Correction and improvement of data
quality should remain the responsibility of the
provider centre.
4. Centres and commissioners should develop data items
to enable local and regional audit of process and
outcomes related to vascular access.
5. A unified standard for patients commencing all forms
of renal replacement therapy, including peritoneal
dialysis and transplantation should be developed in
collaboration with the Renal Association, the British
Renal Society and the British Transplantation Society.
This would provide a better measure of clinical care
when assessing centre performance.
13.2 Access provision1. Late referral should be minimised by joint working
with primary and secondary care to identify
progressive chronic kidney disease.
2. When patients present late, requiring renal
replacement therapy, alternative therapies should be
considered to allow time for the formation of vascular
access.
3. When patients commence dialysis with a venous
catheter, a root cause analysis should be undertaken
to determine the reasons and to improve the process.
4. Research and development into the prediction of
dialysis start dates and the optimal timing of access
placement is urgently required.
34
(Taken from National Kidney Care Vascular Access Audit Report 2011)
35
1. National Kidney Care Audit Vascular Access Report 2011, NHS Information Centre.
2. UK Renal Registry 14th Annual Report. Chapter 1: UK RRT Incidence in 2010: national and centre-specific analyses.
Gilg J, Castledine C, Fogarty D., UK Renal Registry, 2011
3. English Indices of Deprivation 2010
http://www.communities.gov.uk/publications/corporate/statistics/indices2010
4. UK Renal Registry 13th annual report. Chapter 7: The Relationship between the type of Vascular Access used and
Survival in UK RRT Patients in 2006. Castledine C, van Schalkwyk D, Feest T. UK Renal Registry; 2010.
5. Renal Association Clinical Practice Guideline on vascular access for haemodialysis. Fluck R, Kumwenda M. Nephron
ClinPract. 2011;118 Suppl 1:c225-40
6. A randomized, controlled trial of early versus late initiation of dialysis. Cooper BA, Branley P, Bulfone L, et al. for the
IDEAL Study group. NEngl J Med. 2010 Aug 12;363(7):609-19.
7. 'Ideal criteria' for starting chronic hemodialysis: numbers, symptoms or an alerting 'traffic light' system? Arici M.
Nephron ClinPract. 2012;120(1):c17-24. Epub 2011 Dec 21.
8. Transitions in care: what is the role of peritoneal dialysis? Fluck R. Perit Dial Int. 2008 Nov-Dec;28(6):591-5.
14. References
RECOMMEN
DATIONS
AND REF
EREN
CES
36
37
Appendix 1 – 2011 Data Submission Proforma
Audit data item Mandatory/Optional DefinitionUKRR datasetspecification code
ID OHospital number
IDN04
Forename M Forename IDN02
Surname M Surname IDN01
DoB MDate of Birth
IDN03
Gender M Sex PAT00
NHS number M'New' NHS number
PAT13
Post Code MThe postcode of the patient's usualaddress
PAT23
Treatment Centre Code for dialysis MCode of the centre where the patientdialyses. Renal registry code
PAT01
Primary Renal Diagnosis M EDTA Diagnosis code ERF04
BMI OBody Mass Index = Weight in Kg / heightin m2
Date first seen by Renal Physician MThe date the patient was first seen by arenal physician. Outpatient or Inpatientnephrology.
PAT33
Date of first ever RRT MDate of very first dialysis session in 2011
ERF00
Dailysis Modality at First RRT MDialysis modality used at First ever RRTabove (HD, PD, TX)
First Dialysis Access MAccess type in use at first dialysis
ERF12
Assessed by Surgeon for an AVF,AVG or peritoneal dialysis catheterat least 3 months before dialysis
O
Was the patient seen by a surgeonregarding dialysis access at least 3months before their first dialysis dateYes/No
Access in use at 3 months OThe Access in use 3 months after thestart of first dialysis
APP
ENDIX 1
www.kidneycare.nhs.uk
