At the recent Vascular Access Society of the Americas (VASA) 2024 Vascular Access for Haemodialysis Symposium (16–18 May, Atlanta, USA), one of the focal points of the programme was the Global Dialysis Access Forum (GDAF). Divided into two sessions that took place during the first afternoon of the meeting, the GDAF looked at dialysis access care and initiatives in the USA, Japan, India, Europe, Asian Pacific nations and Latin America.
Following an introductory address from Surendra Shenoy (Washington University School of Medicine, St Louis, USA), the first presentation—which was given by Dirk Hentschel (Brigham and Women’s Hospital, Boston, USA)— examined dialysis access initiatives in the USA. The main message from Hentschel was that, as he said, “there’s still room for improvement”.
Reflecting on recent updates to guidelines for dialysis access, Hentschel used two examples to show how challenging he feels it can be to have a guideline with “implementation tools and concrete advice that is applicable across the USA”. Looking at the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, he showed the audience an example of a flow diagram for central venous catheter insertion, specifically looking at the section addressing reduction of complications during catheter insertions.
“What you see there,” he said, “is that it’s recommended to use imaging for central venous tunnel catheter placement. And it gives the option between ultrasound and fluoroscopy. From the setting that I work in—an academic medical centre—there is nobody who would ever dare to place a tunnelled catheter, especially from the left side, without fluoroscopy, just given the complications that have occurred with this.”
Despite this risk associated with not using fluoroscopy for placing tunnelled catheters, Hentschel did concede that, during the COVID- 19 pandemic, there were many instances where tunnel catheters were placed just with ultrasound in life-saving situations, or situations where the benefits would outweigh the risks. Due to this exception, he stated that these guidelines “now have this asterisk that fluoroscopy is preferred and should be used whenever possible”, which he argues can be both too permissive or too strong a guide, depending on the environment you are in and the resources available to you.
Later in this session, after Hideki Kawanishi (Tsuchiya General Hospital, Hiroshima, Japan) gave an update on dialysis access care in Japan, Matteo Tozzi (University of Insubria, Varese, Italy) spoke to the VASA audience regarding the state of dialysis access in Europe. When speaking to Renal Interventions, Tozzi said: “My participation in the global session is really an honour. I focused my presentation on three problems in the cohort of haemodialysis patients in Europe; correct timing for vascular access, elderly patients, and the follow-up for vascular access. It’s imperative to be aware of other data from the global perspective—so from the Japanese Society of Dialysis Access [JSDA], the Asian Pacific Society of Dialysis Access [APSDA], and [our VASA colleagues] as well as from South America. I think the outcomes for our patients are based on sharing the experience from global colleagues that perform this type of surgery, allowing us to improve the outcome of our treatment follow-up, and the quality of life of patients.
Following shortly after Tozzi’s presentation, Takashi Sato (Nagoya Kyoritsu Hospital, Nagoya, Japan) updated the audience on organisational challenges in Asia Pacific nations. Carlos Hinojosa (National Institute of Medical Science and Nutrition, Mexico City, Mexico) was then on hand to give the audience an update on dialysis access care in Latin America. The key message from his talk was clear; there are wide disparities in the level of dialysis access care across Latin America, both within nations and across the region as a whole. “In Central America,” he informed the audience, “there is a huge contrast in the management of vascular access. We can see in Costa Rica, they have a universal system and some of the best work, having one of the best health systems, whilst in Mexico, there is an inefficient public system that not everyone has access to, especially in recent years. Panama has a good system, but they face important problems to give or provide these services to the remote or more inaccessible communities.” As well as this, he stated that other countries, such as Brazil, Argentina, and Colombia, not only have disparities in the level of care available, but also have experienced a rise in the mortality rate.
“The concerning rise in the mortality rates in kidney disease has been noted since 2018 in different regions, and that tells us about the trends in these regions and what healthcare strategies are needed to address that underlying cause and improve the management of chronic renal disease.” Concluding his presentation, Hinojosa stated that “enhancing dialysis access management demands a collaborative and multidisciplinary effort across Latin America”.
When asked by Renal Interventions what he felt the key takeaways were, he said: “We can do much more, we can do better than what we do currently, and we need to communicate better, because there is some fantastic work in different places, but not all the countries have it. We need to carry on this global symposium.”
The final presentation of the session was given by Sanjiv Jasuja (Indraprastha Apollo Hospitals, New Delhi, India), who brought with him some insight into the challenges that accompany the efforts to organise dialysis access in India. Whilst he did say that access to dialysis care is improving in India and South East Asia, he feels that there are still some obstacles to overcome.
“The state economy is very important for us to take on the next level and a lack of time [spent] training hinders the majority of the processes.” It was not all negative, however. “AVATAR [Association of Vascular Access & inTerventionAl Renal Physicians], particularly,” he stated, “has brought a serious change in mindsets, enhanced learning, and supported the implementation of new policies.”
Sharing his thoughts on the value of this GDAF, Jasuja averred that “this is probably one of the finest programmes, because our globe is represented with their thought processes, their achievements, their way of working, and what they are delivering as they are now. For us particularly, coming from South East Asia, this is useful, because we still have a long way to go. It always gives us a challenge, but it also gives us insight, and it gives us kind of an opportunity to interact with our global colleagues and enhance our goals, levels, and our performances. So I think all in all, this is one of the finest programmes at the international level which has a collective approach, that puts everything together.”
Speaking to Renal Interventions about the session, Shenoy stated: “If you step back and think about it, GDAF is a dream come true because you see so many experts from all over the world—pretty much covering the entire global population—sharing the problems seen with their population and their experience, all in one place. It has a lot of potential for global harmonisation of dialysis access care. There are lots of avenues where it can go to where it can help budding physicians and surgeons and nephrologists who are interested in access. So, it’s a great endeavour and hopefully we will be able to now go full force forward with the future meetings in Japan, in the UK or even VAS in Europe. We will continue to do this. We will continue doing the GDAF meetings and see where we can go.”
