Assessing Permanent Dialysis Access in Underserved Patients with Advanced Kidney Disease in Austin, Texas

Background: Arteriovenous fistulas (AVFs) have several advantages over central venous catheters (CVCs), primarily lower complication rates and more reliable blood flow rates. However, many underserved patients with advanced kidney disease start dialysis with CVCs. Methods: In this retrospective study, we reviewed the medical records of underserved patients receiving emergency-only hemodialysis (EoHD) at an academic medical center (January 2022-March 2023), and of non-dialysis dependent patients with estimated glomerular filtration rate (eGFR)<20 ml/min/1.73m2 at two community nephrology clinics (January 2021-December 2023) in Austin, Texas. We assessed the prevalence of each access type. Utilizing questionnaire interviews with health care providers and staff, we discussed barriers to arranging permanent dialysis access and recommendations for intervention. Results: Among 38 patients receiving EoHD, 29 (76%) had an AVF or arteriovenous graft (AVG) whereas 9 (24%) had a CVC. Average time from first hemodialysis to AVF/AVG creation was 104 days. Among 301 patients receiving care at community nephrology clinics, 71 (24%) had eGFR<20 ml/min/1.73m2. Of these 71: 19 (27%) had AVF/AVG, 8 (11%) had been referred to Vascular Surgery but did not have AVF/AVG, 15 (21%) had not been referred to Vascular Surgery, and 29 (41%) did not have any recent clinic notes as they may have transitioned their routine nephrology care to a dialysis center. Noted barriers included: primary language other than English, uncertainty of the patient regarding commitment to being treated with dialysis, need for additional patient education about dialysis, and failure to attend scheduled Vascular Surgery appointments. Recommended interventions included: creating culturally sensitive educational materials, and workflow diagrams for providers/staff for referral to Vascular Surgery. Conclusion: Optimizing permanent vascular access among underserved patients with advanced kidney disease is challenging due to numerous barriers.