During the second day of the St George’s Vascular Access Course, delegates learnt how vascular access in renal failure patients is practised in other countries outside the UK such as Chile, Japan and Greece.
Sergio Valenzuela, Santiago, Chile, gave an overview of the vascular access practice in Chile. He told delegates: “Chile is a developing country in South America with good global health indicators. The health system is mixed between public and private insurance, being the public more than 80%.”
Referring to the numbers of patients with renal failure, he said: “It is growing and the vast majority use haemodialysis as a renal substitution therapy; only a small group use peritoneal dialysis, representing 5%.” Valenzuela explained that the main cause of renal failure in Chile was diabetic nephropathy, and the major vascular access used in treatment was the autologous arteriovenous fistula (77%) followed by a tunnelled catheter (15%).
According to Valenzuela, the main cause of hospitalisation in patients with haemodialysis is problems with their vascular access (25%). These problems included late indications, infections and overuse of catheter. He concluded: “The main challenge for the vascular surgeon is to diminish the amount of catheter use by performing more and better autologous venous fistula.”
Akira Miyata, Kyushu, Japan, presented information about the situation of chronic renal failure patients and recent methodologies of vascular access maintenance in Japan. “According to data from Ministry of Health, Labour and Welfare of Japan, the number of patients enforcing chronic dialysis therapy surpassed 300,000 cases in 2011 and it continues to increase,” he said.
Based on this situation, Miyata commented, the guideline committee of Japanese Society for Dialysis Therapy launched, in 2011, the second edition of an original Japanese guideline titled: “Guidelines for vascular access construction and repair for chronic haemodialysis”.
“The guideline includes information on monitoring and surveillance of vascular access and emphasises the importance to build a therapeutic environment with information-sharing by specialist doctors, clinical engineers, and nurses,” he explained.
He reviewed the statistics on dialysis. The average age for starting dialysis was 66.4%. Figures for renal replacement therapy in the Japanese population in 2009 was 3.4% transplantation, 1.8% peritoneal dialysis and 94.8% haemodialysis.
Miyata added that the number of haemodyalsis centres in hospitals in Japan was 2339 and was 1832 in clinics (total 4271). The number of haemodyalsis machines in Japan was 121,835, and he noted that one haemodialysis centre is capable of treating 70.2 patients.
He also reviewed the Japanese statistics and said that diabetic nephropathy was a major cause of end-stage renal disease and its incidence was increasing, with the number of kidney transplantations continuously increasing—particularly living-donor kidney transplantations. Glomerulonephritis was the second cause of end-stage disease, but its incidence was decreasing. Miyata commented that most end-stage renal disease patients were treated by haemodialysis, even though number of medical treatment is increasing.
He concluded: “Because of ageing and the increasing use of haemodialysis,—plus the increasing number of diabetes mellitus patients—Japanese social health insurance will encounter a very big challenge. The creation and maintenance of vascular access is becoming difficult for all players, because of aging and diabetic nephropathy of haemodialysis patients. We believe that information-sharing and cooperation among the specialist doctors, clinical engineers, and nurses is crucially important.”
Miltos Lazarides, Alexandroupolis, Greece, summarised the current status of vascular access training in Greece, as being a collateral effect of the Greek economic crisis. He said that the access surgeon is involved in many medical specialties and “has not the glamour of other major vascular operations.”
He told the audience that, although 15 units have been accredited for vascular surgery training in Greece, only a third have been exposed to access surgery.
The Greek economic crisis, he said, imposed austerity measures; therefore no new vascular surgery posts were offered in the Greek National Health Service. He added that there was a shortage of operating lists as nursing staff numbers were reduced and there was increased focus on the arterial workload as a result of centralistion of vascular services.
Lazarides said, in his department in the Greek region of Alexandroupolis, that only half a day list per week has been devoted to access surgery, and within this given time-frame only three primary autologous arteriovenous fistulas or two more complicated cases can be performed a week.
In conclusion, Lazarides said: “The new generation of general surgeons have fewer opportunities to develop expertise in vascular access creation.” However, he added that a new six-month training programme had been launched for already-qualified surgeons and trainees in vascular surgery to counteract this.