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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;<br></br><br></br>Haemodialysis &#40;HD&#41; constitutes the first option of Renal Replacement Therapy &#40;RRT&#41; in incident patients&#44; and the second in prevalent patients&#44; according to the SEN &#40;Spanish Society of Nephrology&#41; record of 2006&#46;<span class="elsevierStyleSup">1</span> According to the 2006 Renal Patients Registry in Extremadura&#44;<span class="elsevierStyleSup">2</span> 87&#46;07&#37; of incident patients and 52&#46;55&#37; of prevalent patients on RRT were on HD&#46;</p><p class="elsevierStylePara">In the province of Caceres&#44; HD is the first RRT option in incident patients &#40;85&#46;7&#37;&#41; and prevalent patients &#40;51&#46;8&#37;&#41;&#46; Given that Vascular Access &#40;VA&#41; conditions the effectiveness of HD&#44; the morbidity and mortality &#40;major cause of hospital admission&#41; and their quality of life&#44; makes the creation of a proper VA urgent&#46;</p><p class="elsevierStylePara">In order to review the current VApractice in our province and compare it to that from Spain&#44; Europe and the United States and to evaluate the level of compliance with the quality standards recommended in the SEN<span class="elsevierStyleSup">3</span> and the K&#47;DOQI Vascular Access for HD Guidelines&#44;<span class="elsevierStyleSup">4</span> we have carried out a retrospective&#44; observational study of VAin incident and prevalent HD patients in 2007&#46;</p><p class="elsevierStylePara">A multicentre study published in 2001 by the Vascular Access Work Group is used as the main reference for VA practice at the national level<span class="elsevierStyleSup">5</span> and at the international level&#44; the DOPPS study&#44;<span class="elsevierStyleSup">6</span> which examines the trends in VA use in Europe and in the United States&#46;</p><p class="elsevierStylePara">We found that during 2007&#44; of the 45 HD patients that started treatment &#40;incident population&#41;&#44; 28 &#40;62&#46;2&#37;&#41; patients had permanent VA &#40;53&#37; native AVF&#44; 7&#37; graft and 2&#37; permanent catheter&#41; and 17 &#40;37&#46;8&#37;&#41; had no vascular access &#40;table 1&#41;&#46;</p><p class="elsevierStylePara">When compared with the National&#44; European and North American references&#44; the report on vascular access from 2001 revealed that 56&#37; of patients started HD with a definitive VA and 44&#37; with a temporary catheter&#46;</p><p class="elsevierStylePara">According to DOPPS&#44; in the United States 60&#37; of patients began HD with venous catheters &#40;59&#37; tunnelled and 41&#37; temporary&#41;&#59; that is&#44; 75&#37; of all HD patients had definitive VA&#46; Whereas in Europe&#44; 31&#37; of patients commenced HD with a catheter&#44; 25&#37; of them tunnelled and 23&#37; had no definitive VA at the start of HD&#46;</p><p class="elsevierStylePara">The vascular access in HD guidelines of the SEN recommend&#44; as a quality indicator&#44; that 80&#37; of the patients that start HD should have a permanent VA&#46; Regarding this target&#44; our province is under achieving&#46; When we examined the different types of definitive VA in use in our province&#44; we found 53&#37; of patients have a native AVF&#44; 7&#37; have a graft and 2&#37; have tunnelled catheters &#40;table 1&#41;&#46; The Spanish study of the VA group does not offer comparative data and&#44; according to the DOPPS&#44; in Europe 66&#37; started HD with a native AVF&#44; 2&#37; with a graft and 8&#37; with tunnelled catheters&#44; while in the United States&#44; only 15&#37; used a native AVF&#44; 24&#37; grafts and 25&#37; tunnelled catheters&#46;</p><p class="elsevierStylePara">The K&#47;DOQI guidelines of 2006 recommend a native AVF rate of 50&#37; or greater in incident patients as the clinical standard&#46; In this regard&#44; our province complies with this guideline&#46;</p><p class="elsevierStylePara">Concerning the temporary VA&#44; 17 patients started HD with a catheter&#58; one subclavian&#44; 9 femoral andseven jugular and they were used during an average time of 11&#44; 34 and 64 days&#44; respectively&#46;</p><p class="elsevierStylePara">The K&#47;DOQI guidelines recommend that temporary jugular catheters should not be left in place for more than a week&#44; and less than 5 days for femoral catheters&#46; The VA guidelines of the SEN advise that femoral catheters should not be left in place for more than seven days&#44; and although they do not address the jugular catheters&#44; they recommend that if the catheter is going to be left in place for more than four weeks&#44; it should be tunnelled&#46;</p><p class="elsevierStylePara">Regarding the VA in the prevalent population&#44; as of 31 December 2007 of the 185 patients that were on HD&#44; 139 &#40;75&#37;&#41; had a native AVF&#44; 13 &#40;7&#37;&#41; grafts&#44; 23 &#40;12&#37;&#41; permanent catheters and 10 &#40;6&#37;&#41; temporary catheters &#40;table 1&#41;&#46; When we analysed separately the practice in the hospital and in the satellite renal units &#40;table 2&#41;&#44; we can see that the percentage of native AVF is much greater in the peripheral centres&#44; while the use of central venous catheters is greater in the hospital&#46; This is most likely due to the fact that older patients and those with greater comorbidity are hospital-based&#46;</p><p class="elsevierStylePara">The SEN Report on vascular access of 2001 stated that 80&#37; of the patients had native AVF&#44; 9&#37; grafts and 11&#37; catheters&#46; Data from the DOPPS study show that in the United States there was a greater use of grafts &#40;58&#37; &#41; and&#44; 24&#37; native AVF&#44; 10&#37; permanent catheters and 7&#37; temporary catheters&#46; Whilst in Europe 80&#37; of patients had native AVF&#44; 10&#37; prosthesis&#44; 6&#37; tunnelled catheter and 2&#37; temporary catheter&#46; The VAguidelines of the SEN from 2005 propose&#44; as a quality indicator&#44; that the majority of the patients use a native AVF for dialysis&#44; recommending a rate of at least 80&#37;&#46; Our province is below this target achieving 75&#37; native AVF in our HD population&#44; that is 78&#37; in peripheral centres and 65&#37; in hospital&#46;</p><p class="elsevierStylePara">Regarding the tunnelled catheters&#44; the SEN guidelines consider as quality criteria the minimization of their use as a permanent access&#44; recommending &#60; 10&#37;&#46; In our province&#44; 12&#37; had this type of VA &#40;16&#37; in hospital and 11&#37; in peripheral centres&#41;&#46;</p><p class="elsevierStylePara">The multicentre Spanish study does not differentiate between permanent and temporary catheters&#44; and thus this information is not available at a national level&#46; Regarding DOPPS&#44; in Europe the use of tunnelled catheters was found in 6&#37;&#44; and in the United States&#44; 10&#37; of HD patients&#46;</p><p class="elsevierStylePara">Our study reveals that currently the VA situation in our province is not adequate&#44; with an elevated percentage of patients that begin HD with temporary access that is left in place longer than recommended&#46; Regarding prevalent patients&#44; the rate of native fistulae is below the recommended standard set in the clinical guidelines&#46; However our number of permanent catheters is above target&#44; especially at the hospital level&#46; To improve appropriate VA rates at the start of HD&#44; a multidisciplinary approach is needed between Primary Care&#44; referring patients early&#44; and nephrologists and vascular access surgeons&#46; Regarding patients that are already on dialysis&#44; a periodic evaluation is needed of their vascular access to detect potentially repairable malfunctions that might result in the loss of the access site and that would compromise future vascular sites&#44; and to limit the use of temporary catheters&#46;</p><p class="elsevierStylePara"><a href="grande&#47;21518078&#95;t1&#95;p178&#46;jpg" class="elsevierStyleCrossRefs"><img src="21518078_t1_p178.jpg" alt="Types of vascular access in incident and prevalent patients"></img></a></p><p class="elsevierStylePara">Table 1&#46; Types of vascular access in incident and prevalent patients</p><p class="elsevierStylePara"><a href="grande&#47;21518078&#95;t2&#95;p179&#46;jpg" class="elsevierStyleCrossRefs"><img src="21518078_t2_p179.jpg" alt="Types of vascular access in prevalent patients in the different centres"></img></a></p><p class="elsevierStylePara">Table 2&#46; Types of vascular access in prevalent patients in the different centres</p>"
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