Practical and ethical challenges of maintaining vascular access in chronic kidney disease: A qualitative interview study

Abstract

Objective

Chronic kidney disease affects 16.8% of adults in the United States, for which hemodialysis is most commonly used for renal replacement therapy. Although emphasis with the Fistula First Initiative has historically focused on the prioritization of autogenous arteriovenous access, higher rates of maturation failure and access dysfunction have prompted a reappraisal of this approach in the literature and clinical practice. Oftentimes, frail or medically complex patients with dysfunctional access are subjected to a large number of surgical procedures to maintain or reestablish patency. The influence of arteriovenous fistula (AVF) dysfunction and repetitive reintervention on patient experience and quality of life remains largely unexplored in contemporary literature.

Methods

Using a provincial database of renal failure patients (Patient-Reported Outcomes Measurement Information System [PROMIS]), we selected patients who had undergone five or more interventional procedures (open or endovascular) to maintain vascular access within a 20-year period from a single institution. Semistructured interviews were conducted with these patients and analyzed qualitatively using the constant comparative approach.

Results

Seventeen patients who met the inclusion criteria were recruited from across British Columbia. The cohort included patients from both genders (10 male, 7 female) between the ages of 52 and 87 years old. Four major thematic categories were identified; treatment values, impact of disorder, disposition toward AVF and impact of repeated interventions. Survival was the primary theme in the treatment values category (11/17), with reduction in dialysis frequency being secondary. Within impact of disorder, loss of independence was the primary theme (14/17), with psychological impact being secondary. Displeasure with the high rates of failure emerged as the primary theme (15/17) in disposition toward AVF, with pain with use (8/17) and inadequate informed consent (8/17) as secondary themes. Finally, for impact of repeated interventions, the primary theme was interruption to daily life (12/17). Overall, only 8 of 17 patients expressed satisfaction with their AVF.

Conclusions

These findings highlight that repeated interventions to maintain fistula patency pose significant disruption to patient's quality of life. Rates and impacts of fistula failure need to be explained thoroughly to patients during their informed consent process, moving toward a more patient-centered, individualized and holistic approach to vascular access over a ubiquitous fistula-first approach in all cases.