The management of dialysis access thrombosis during the COVID-19 pandemic

Abstract

Background: Maintaining patent access is essential for haemodialysis dependent end stage renal failure patients. The COVID-19 pandemic has significantly affected surgical and interventional radiology services worldwide. We aimed to review the impact COVID-19 has caused to the management of acute dialysis access thrombosis. Methods: We conducted a single centre retrospective review of outcomes of patients with arteriovenous fistula and arteriovenous graft thrombosis between March and May 2020, which coincided with the first peak of the COVID-19 pandemic in London, and a similar period in the previous year, March–May 2019. Outcomes in both cohorts of patients were compared, including attempts at salvage, salvage success, 1-month patency rates after salvage and subsequent surgery on the same access. We also analysed the use of tunnelled haemodialysis lines (THL), either due to failed salvage attempts or when salvage was not attempted. Results: There was a similar incidence of access thrombosis in both periods (26 cases in 2019, 38 in 2020). There were 601 patients dialysing via an arteriovenous fistula or graft in 2019, and 568 patients in 2020. Access salvage, when attempted, had similar success rates and 1-month patency (salvage success 74% vs 80%, p = 0.39; 1-month patency 55% vs 62%, p = 0.69). The proportion of patients where access salvage was not attempted and a THL inserted was significantly higher in 2020 compared to 2019 (32% vs 4%, p = 0.007). There were more patients who subsequently had surgery to salvage or revise the same access in 2019 compared to 2020 (62% vs 13%, p < 0.001). Conclusions: During the peak of the COVID-19 pandemic, there were fewer attempts at access salvage. This was a conscious decision due to increased pressure on the healthcare system, access to emergency interventional radiology or operative theatres and the perceived risk/benefit ratio of access salvage. The long-term effects of this change in practice remain unknown.

Impact of the COVID-19 pandemic on the kidney community: lessons learned and future directions

“…CKD, including end-stage kidney disease (ESKD), is associated with an increased risk of COVID-19 and subsequent adverse outcomes including hospitalization, respiratory failure and mortality 2 , 22 – 24 , with risk proportional to kidney dysfunction 22 , 24 . There have been care delivery repercussions, including the postponement of kidney biopsies 25 , delays in arteriovenous fistula surgery and salvage, and disruption in the initiation of KRT 26 . There was a notable decline in incident ESKD in the USA early in the pandemic, because of both increased mortality in patients with advanced CKD and compromised access preparation for KRT 27 .…”

COVID-19 in dialysis: clinical impact, immune response, prevention, and treatment

“…Thrombotic events are a major cause of COVID-19 morbidity 121,122 . Dialysis patients with COVID-19 may experience arteriovenous fistula thrombosis 123 , mechanical dysfunction of the catheter or circuit clotting 124,125 , although no excess of vascular access thrombosis was observed in another study of 601 patients with arteriovenous fistula/graft 126 . Prophylactic anticoagulation is an essential therapeutic strategy for dialysis patients, in accordance with recommendations for the non-dialysis population.…”

Impact of COVID-19 pandemic on hemodialysis access thrombosis

“…A similar study performed in the United Kingdom by Seet et al 9 examined the vascular access salvage attempts, salvage success, 1 month patency and the use of tunneled dialysis catheter following unsuccessful salvage during COVID-19 pandemic in 2020 and a similar time period in the previous year. They found more cases of access thrombosis during COVID-19 pandemic but was not statistically significant.…”