Live blogging the Annual Dialysis Conference - the Sunday General Session

By Bill Peckham

The General Session is just starting:

9:00 Welcome - Karl Nolph, MD

This year's Annual Dialysis Conference is marking 30 years this year and continues its mission of bringing all dialysis modalities together under one roof.Next year's conference is at the Phoenix Convention Center February 20 to 22, 2011.

9:10 Leonor Ponferrada, BSN, RN

Physicians, nurses, social workers and dietitians can all receive CE credit for attending the sessions over the next three days.

9:10 Rajiv Saran, MD, Keynote Address: The Wide Disparity in AV Fistula Creation and Usage between US and the Rest of the World: What is the Explanation?

This has been an issue for many years - why are there big differences between fistula use in the US vs Europe and Japan? The DOPPS data shows that most countries have a good record of fistula rates, though there is some catheter growth. The US has seen a growing rate of fistula use over the period of DOPPS I> II> III now at 44% in the US. While the overall mortality rate is higher in the US, once you adjust for facility level differences the mortality risk in the US drops to about 6%.

There is big difference in fistula placement in US and Canada among men and women while in Japan particularly but is also seen to a lesser degree in Italy and France (data confined to non diabetics) there is little gender difference in fistula placement. Fistulas are cannulated commonly in the first month in Japan but rarely in the US. Initial unpublished data shows lower Qb in a unit is associated with higher fistula use at he facility.

US docs don't place many fistulas during their training, data shows docs who place more than 25 fistula during their training persists and results in shorter average fistula lifespan. 2009 CMS data indicates that fistula placement has grown to over 50% largely due to Fistula First. The US fistula rates have wide variability across the United States, and can be seen as varying facility to facility.

9:40 Michael Flessner, MD, Keynote Address: Stephen Vas Memorial Lectureship - Advances in Maintaining Peritoneal Membrane Health

The chronic inflammation seen in PD may be linked to the PD fluid. It may be the buffer but that hasn't been proven. Lower glucose looks to offer a benefit as does Icodetrin. Icodetrin seems to preserve the peritoneal barrier. The best and easiest tactic to avoid PD problems is to control sodium. Work is being done on alternatives to glucose.

Live blogging a PD presentation is hard since I have a big PD knowledge hole.

Catheter material makes a difference in inflammation, need better materials. A whole system approach is needed to maintain the peritoneal barrier. Many moving parts to track, their interplay varies between patients.

Comments

[Zach]

I may be wrong, but in Japan, many nephrologists are trained for AV fistula placement.

[Bill Peckham]

I'll try to catch Rajiv after the session and ask.

[Bill Peckham]

I finally remembered to ask Dr. Saran your question Zach - the DOPPS data really shows that the strong correlation is to how many procedures the surgeon did during training, not to whether or not the surgeon is a nephrologist.

One example Dr. Saran mentioned is that Italy is where the surgeon is most likely to be a nephrologist (about 80% compared to Japan's 50%) yet still Japan has the better outcomes and the Italian outcomes correlate well based on their moderate experience during training.

I would speculate that this training number is a surrogate for the esteem with which the procedure is held and/or the number of different procedures the surgeon is trained to do. Dr. Saran pointed out that in the US vascular surgeons are trained to do 50 some different procedures, some of which are no doubt more immediately life saving.

Maybe in Japan fistula surgeons have a limited type of surgeries they would undertake in comparison ... which if they were nephrologists would make sense, but bottom line to me:
If you need to have a fistula placed, no matter where you live in the world, ask your potential surgeon how many fistula procedures they did during their training.