Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres.

OBJECTIVE: It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed. METHODS: All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined - the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05. RESULTS: There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity. CONCLUSIONS: In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.

Renal replacement therapy for stage 5 chronic kidney disease in the Cayman Islands.

There has been no documentation on the epidemiology of end stage renal disease (ESRD) in the Cayman Islands. We retrospectively surveyed all facilities providing renal replacement therapy in the Cayman Islands in order to define the epidemiology of kidney failure in this setting. The prevalence of ESRD in this population was 0.975 persons per 1,000 population. There were 48 patients with kidney failure who received replacement therapy either by chronic hemodialysis (36) or kidney transplants (12). The method of access for maintenance hemodialysis was tunneled internal jugular catheter access (3), native arteriovenous fistulae (13) and prosthetic arteriovenous grafts (20). Currently, there is a low prevalence of maintenance hemodialysis by native fistulae (36.1%). A directed effort to increase the use of native fistulae is now necessary to meet the goals set by the National Kidney Foundation and Center for Medicaid Services. Otherwise, renal replacement therapy for patients with ESRD in the Cayman Islands exceeds the standards recommended by the National Kidney Foundation. In order to ensure continued delivery of modern quality care, further audits of the local practice will be required at regular intervals.