All About a Nephrologist Referral to a Vascular Surgeon

Why you should be referred to a nephrologist or vascular surgeon as soon as possible

An early plan for venous preservation should be a substantial part of pre-dialysis care and education in any chronic kidney disease (CKD) patient regardless of the choice of treatment.

In order to allow adequate time for planning the necessary measures and preserving access sites, early referral to a nephrologist and vascular surgeon is strongly recommended in the following cases:

  1. Patients reaching stage 4 of CKD
  2. Rapidly progressive nephropathy
  3. Specific clinical conditions such as diabetes or severe peripheral vascular disease.

 

Because an autogenous fistula requires at least 6 weeks for maturation before it can be used, it is recommended that the fistula is created at least 2-3 months before the earliest likely date for starting haemodialysis. Prosthetic graft AVFs do not need a maturation period and can be cannulated 2-3 weeks after implantation. However, prosthetic graft AVFs are not recommended as primary vascular access.

Early referral to a nephrologist is also required for psychological preparation for dialysis, discussion of all options for dialysis modality, interventions delaying the progression of renal damage, and correction of the hypertension, anaemia, and metabolic effects of renal failure.

 

The importance of an early referral to a nephrologist or vascular surgeon

Studies have demonstrated that early referral to a vascular surgeon is associated with lower risk of sepsis and mortality. It is difficult to predict the timing of haemodialysis onset in an individual patient, however, it has been suggested that vascular access placement less than 6 months before the initiation of haemodialysis is unlikely to allow adequate time for autogenous access maturation. Timely consultation could help avoid these adverse outcomes.

 

In the United States many patients are not referred to a nephrologist until their kidney disease is already quite advanced, allowing little opportunity for vascular access placement before dialysis is initiated.  Not surprisingly, patients who are referred to nephrologists before the initiation of dialysis are more likely to undergo vascular access surgery before dialysis begins. In addition, pre-dialysis nephrology referral is associated with a shorter duration of catheter use after the initiation of dialysis and with a greater likelihood of autogenous access placement.

 

Pre-operative evaluation

Establishing functional AV access requires careful preoperative vascular evaluation and planning. This process starts with the early identification of individuals with renal insufficiency and prompt surgical consultation to select the best extremity and site for an autogenous AV access. A very important determinant of the success of AV access is an appropriate and detailed preoperative history and examination followed by vessel mapping.

Early patient referral and organization of pre-dialysis care are major issues that should be kept in mind by both medical staff and patients.

 

 

References:

http://www.vascularaccesssociety.com/resources/media/Guidelines/1_patient_referral.pdf

http://www.vascularaccesssociety.com/intro/guidelines

http://www.sciencedirect.com/science/article/pii/S0741521408013992