Evaluation of dialysis access care by means of process quality indicators.

Improvement of dialysis access management depends on technical skill but also on effective choice, construction, monitoring and revision of the access. Surgical procedure is only one step of a complex course, beginning with the referral of patients to nephrologists. Using two process quality indicators, we describe the evolution of access management at our centre, where access surgery and access-related activities are performed by nephrologist. The first process indicator is based on the prevalence of temporary access at first dialysis (TA1st) in end stage renal disease ESRD patients, the second one measures the prevalence of permanent central venous catheters (%CVC) in dialysis population. TA1st increased to 27.1% in 1999, more than twofold compared to the previous year. There was also an increase in %CVC from 20.6 to 26.3%. Native access remained the most utilised, well above 70% of dialysis patients. Our process monitoring suggests a rapid worsening of late referral, as indicated by the increasing use of temporary catheters at the beginning of chronic dialysis. Increasing surgical activity and diagnostic procedures were only partly effective in containing the rise in CVC. Venous sparing, early referral, Continuous Quality Improvement and a multiprofessional access-team co-ordinated by a nephrologist could be the key-elements in facing the never-ending-story of dialysis vascular access.

Vascular access for haemodialysis: from surgical procedure to an integrated therapeutic approach.

During the past 10 years the type of vascular access for haemodialysis procedures have changed markedly in our centre: more elbow AV fistulae and more central venous catheters are now used. Nevertheless, early referral to nephrologists and availability of central venous catheters and peritoneal dialysis allow elderly people to be admitted for dialysis treatment. Since vascular access for haemodialysis plays a key role in patient well-being, it is mandatory to apply quality assurance criteria to vascular access for haemodialysis surgery. Based on the results of a national survey, in Italy this policy is still in its early stages: monitoring of vascular access differs amongst centres, interventional radiology is used in a differing way, planning of vascular access for haemodialysis in pre-dialysis patients often remains an unsolved problem. According to our initial experience, we propose the use and validation of a quality-index [(minimum success rate) in elective vascular access for haemodialysis surgery], allowing accreditation of a department and a single surgeon for access management. Prevalence of central venous catheters at first dialysis of chronic renal failure patients is also proposed to evaluate the efficiency in access planning. Better knowledge of vascular access management by different teams could eventually lead to definition of guidelines for this 'Cinderella of dialysis'.

Absence of rejection in cryopreserved saphenous vein allografts for hemodialysis.

Since November 1987, a total of 16 dialysis patients in the authors' Center, received a cryopreserved saphenous vein allograft (CSVA) as "third choice" vascular access. ABO and HLA-A-B compatibilities were determined but not considered. Saphenous veins were cryopreserved in liquid nitrogen for variable periods (1-6 mo), so that there was the opportunity to choose the most suitable in dimension. In February, 1989, a total of 13 patients retained a well-functioning access site, whereas three had died from causes unrelated to CSVA. Because rejection of venous allografts still is debated among angiologists, recipient T lymphocyte subsets (CD3-CD4-CD8 and CD4/8) were examined, as were lymphocytotoxic antibodies, before and on days 15 and 30 after implantation. No evidence of immunologic activation was found. Moreover, in 10 of 16 patients the surgeons subcutaneously implanted a fragment of CSVA, and an immunohistochemical study was carried out using an alkaline phosphatase-antialkaline phosphatase (APAAP) technique and a panel of monoclonal antibodies. Minimal infiltration of the outer layer of adventitia was found, mainly caused by monocyte macrophages (Leu M3+) with few T lymphocytes (CD3+). The authors conclude that rejection is not a major cause of failure in CSVA in dialysis patients.

Neurobehavioural comparison of low-risk preterm and fullterm infants at term conceptional age.

The neurobehavioural performances of 20 low-risk preterm infants born at 33 weeks gestation or less were examined with the Brazelton Scale at the expected date of delivery, and 20 healthy fullterm infants were also examined on the fifth day of life. The preterm infants were significantly inferior in orientation, motor performance, regulation of state and autonomic regulation. With the exception of autonomic regulation, the neurobehavioural clusters were more heterogeneous among the preterm group. The data suggest that low gestational age at birth, even following relatively normal pre-, peri- and neonatal development, is associated with a behavioural repertoire which is different, more heterogeneous and on average poorer than that of fullterm infants.