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Most Dialysis Patients Aren't Receiving The Best Treatment

When kidneys fail to cleanse the blood, dialysis is often the solution. But the odds for success over the long haul depend in no small measure on the details of how the dialysis machinery is connected to the patient.

For the past 20 years, doctors have recommended that dialysis patients have a simple operation to make it safer and easier to connect to a machine that cleans their blood.

Yet only 20 percent of new dialysis patients are receiving the lifelines known as arteriovenous fistulas, a study published Wednesday in JAMA Surgery finds. With about 100,000 people starting dialysis each year, that means 80,000 patients aren't receiving the preferred standard of care, putting them at a higher risk of infection, blood clots and even death.

"Doctors are usually really good about following standards of care and recommendations, but in this area, we are failing miserably," said Dr. Mahmoud Malas, a surgeon at Johns Hopkins University School of Medicine who led the study. "We have had recommendations for [the best possible care for] 20 years now, but after all this time, only about 20 percent of those starting dialysis are getting it done right."

Kidneys play a vital role in our daily lives. They constantly clean our blood, removing harmful toxins that are eventually disposed through our urine. When someone's kidneys fail, the organs can no longer perform this essential function and weekly dialysis treatment is used in their stead.

Connections called arteriovenous fistulas are the preferred method for patients to connect to hemodialysis machines. Surgeons stitch together an artery and vein, usually in the arm, to create a sturdier vein with greater blood flow. The fistula reduces dialysis treatment time, while increasing the effectiveness of the blood cleaning.

Fistulas are also safer. "Chances of you dying are 30 to 40 percent less if you use a fistula," Malas says.

Despite these clear benefits, only about 1 in 5 new dialysis patients receive fistulas, according to national data analyzed by Malas and his team.

The researchers collected data from the U.S. Renal Data System, which tracks all patients with end-stage renal disease. They looked at 464,547 individuals who began dialysis between January 2006 and December 2010.

Texas, Florida and South Carolina had the lowest number of ESRD patients obtaining fistulas, with only about 1 in 9 patients receiving fistulas. But instead of pointing the finger at the puny performance of those three states, Malas says it's more important to see the bigger problem.

"Even if you look at the region that had the highest incidence of fistulas, which was New England, they only had a 22.2 percent usage," he says. "That's still pathetic."

"This is an opportunity for improvement in general," says nephrologist Joe Vassalotti, who works at Mount Sinai Hospital in New York. "It's a call to action for the whole country. Everyone would agree that more than 20 percent of patients should be starting with fistulas. Everyone would agree we can do better."

So what's stopping new dialysis patients from getting fistulas?

Malas' research documents the heavy dependence on catheters for dialysis. These are small plastic tubes, usually placed in a vein along the neck, chest, leg or groin, that are open to infection. However, the tubes mean patients don't have to be stuck with needles during dialysis.

"Some patients don't want to be poked," Malas says. "They don't want a needle going into their arm three times a week like fistulas require."

But more importantly, he says, primary care doctors may not be vigilant enough for kidney disease in the first place.

"I don't think doctors are failing," he says. "I think they are overwhelmed by seeing so many patients every day, and it's very hard to recognize when kidneys start deteriorating. Kidney failure can be symptomless and silent for a long time. It's easily missed."

And if it's missed, patients can suddenly "crash into dialysis," requiring emergency hospitalization and dialysis. Catheters are the quickest ways to treat emergency kidney failures because they can be used immediately after insertion. Fistulas, on the other hand, cannot be used for six to 12 weeks after the operation.

To avoid dialysis crashes and emergency use of catheters, Malas recommends doctors pay special attention to patients who have a family history of kidney disease, hypertension and diabetes, which are risk factors for kidney failure.

Once kidney failure is recognized, it helps to get a nephrologist — or kidney specialist — involved quickly. Patients assigned to nephrologists are 11 times more likely to receive fistulas than those without one, according to the study.

"I think what's really important about this research is that it emphasizes seeing nephrologists," says Mount Sinai's Vassalotti, who is also the lead clinical consultant for Fistula First Catheter Last, a national initiative to increase the use of fistulas. "People living with kidney disease should prepare in advance and have fistula surgery before they crash and before it's too late."

Receiving a fistula operation takes months of preparation, but nephrologists can get the process going early on, he says.

Malas says that he hopes his study will make patients and doctors more aware of kidney disease and the benefits of dialysis via fistulas.

"Fifteen thousand deaths occur each year because the wrong method of dialysis is being used," he says. "This country could save thousands of lives if we start doing the right thing."

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