Michigan Dialysis Research and Education, Inc.

MiDRE ("my dray") – a non-profit corporation formed to improve dialysis care in Michigan. It seeks to achieve this via several initiatives

  1. Dialysis outreach – from MiDRE to the units for problem solving and education
  2. Vascular access education for dialysis unit personnel – in the office and hospital
  3. Presentations by Dr. Webb
  4. Research and publication of results pertinent to dialysis provision
  5. Links to other resources

Background

End-stage renal disease is a disease entity that currently affects over 400,000 people in the United States, and whose management involves hemodialysis in the majority (>80%) of patients. Nearly every renal failure patient, whether transplanted or choosing peritoneal dialysis (CAPD) will undergo hemodialysis at some time. Systems for providing dialysis care are well established in the United States. Unfortunately, hemodialysis requires passing large amounts of blood through a dialysis filter three times a week: 90,000 to 120,000 milliliters; 90 to 120 liters; or 23.7 to 31.6 gallons over a session repeated three times a week). There is no vein in the human body that can withstand this amount of use without modification.

There are essentially three options that allow for this volume of blood to be drawn from the body, run thought the dialysis machine, and returned to the circulation:

  1. A large catheter with two channels can be placed through the skin into one of the major veins with sufficient flow to provide this amount of blood and safely handle its return
  2. A native vein of the patient which has been conditioned by a direct connection with the arterial pressure and flow of an artery to expand, to carry sufficient flow, and to toughen enough to safely and repeatedly handle being punctured by large needles twice a week (called a "fistula")
  3. An artificial tube connecting an artery and vein, placed under the skin, and also designed to be safely punctured three times a week with large needles (called a graft)
As one can imagine, each of these options requires some alteration of the normal body function, and each carries some risk. Provision of these means is necessary for each dialysis patient, and as each option represents an unstable system prone to failure and complications, there has been much effort and debate escalating recently over how best to provide the safest and most stable option possible. The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) released a landmark example of evidence-based medicine in 1997 with benchmarks and clinical guidelines. Much of the debate since then has been driven by this effort, with definite signs of quality improvement, and there are organizations existing to help define and drive needed changes (i.e., the Renal Network and its regional branches, the "Fistula First" collaborative, the Controversies in Dialysis Access [CIDA] meeting, the Vascular Access Society of the Americas [VASA] and its biennial meeting, the American Society of Diagnostic and Interventional Nephrologists [ASDIN] and their yearly meeting, journals such as "Seminars in Dialysis", and so on). However, as a surgeon focusing on the care of these patients full-time for over a decade, and as one of the busiest surgeons in this field in my region, my observation is that much remains to be done to achieve the quality levels that we want to see.

As a practicing surgeon with a deep interest in quality improvement, I am torn between my desire to provide direct relief to those patients who come to me with their problems, and my desire to take time to do clinical research and teach; torn between the need to remain productive to financially support my mission, and the reality that other important tasks are NOT compensated by anyone, so that time spent on those other tasks represents money out of pocket. In reality, my practice has invested hundreds of staff hours in data gathering and tracking of outcomes, but realistically there is only so much that a single solo surgical practitioner can support. This ongoing effort represents a level of service which is not compensated in any billing scheme, and which is not duplicated by any other entity in our region to my knowledge.

We are ready to take quality promotion to a new level on a regional and community level, using MiDRE to provide a framework in which important clinical research can continue to be done and published, from which outreach to dialysis units can result in a greater understanding of dialysis conduits, their common complications, and thereby decrease cannulation problems, and from which Dr. Webb’s extensive personal experience can be made available to other surgeons in the region, increasing exposure, dialogue, and hopefully quality.

Initiatives

Dialysis outreach – sending an experienced representative from the practice to the units



Creating an arteriovenous shunt to allow for the provision of hemodialysis is no small feat, and successfully cannulating these shunts with two large needles three times a week for dialysis is no small feat either. All too often there are difficulties, and then the players may start pointing fingers and blaming the others – the surgeon blames the inept dialysis techs, the techs blame the surgeon who has not provided a "good" fistula, and the family talks about moving to a new unit, or seeks a second opinion from another surgeon.

The reality is that this is a very difficult area, and the patient is caught in the middle. The ability to work together to solve the problem is key to getting the permacath out. We need better communication and cooperation between the surgeon’s office and the dialysis unit. We do make it a practice to examine nearly every AV access we see with ultrasound every time we release a fistula for use, and we do provide an ultrasound-assisted digital photo diagram to guide cannulation for nearly every fistula and some grafts, yet this is sometimes not enough to avoid problems.

I have since the beginning of my practice hired experienced dialysis technicians to work in the office with me (Lucretia, Christina, Stacy, Lynne and Ramsis over the years), and have found that they understand the problems of dialysis patients most acutely, having shared the difficulty and occasional frustration of dialysis cannulation. In the last two months one of my high-performers, Ramsis Georgi, has begun visiting the regional dialysis units to demonstrate cannulation techniques, to discuss new products (the HeRO graft catheter and Flixene early cannulation grafts), to discuss access complications and to open dialogue between the surgeons practice and the units. We have a portable ultrasound that can be used in the units to show dialysis personnel what we see every day under the skin, and to help them understand the anatomy and the complexities of these dialysis accesses. Ramsis has been well received so far and will be instrumental in this part of the effort.

There are other "Correct Cannulation" programs out there, and we hope to interface and cooperate with them all.

Access to our extensive clinical photographs of complicated dialysis accesses, the corresponding ultrasounds, the corresponding diagnostic and therapeutic contrast studies, and intraoperative images will allow us to put together "case studies" for presentation during these visits to the units, at Dr. Webb’s talks, and on the internet.

Vascular access education for dialysis unit personnel – in the office and hospital



Michigan Vascular Access, PC, MiDRE, and Saint Marcy Mercy Hospital have cooperated to provide an experience in vascular access for dialysis unit personnel. One half day is spent in the Michigan Vascular Access, PC, o0ffice, seeing the evaluation of new patients, with ultrasound examination to determine options, advice for the patient, and the arrangements for surgery; or the evaluation of old patients who have developed new problems; or of the management, evaluation and release of recently created fistulas, with production of the ultrasound-assisted digital photo diagrams for safe cannulation (link to discussion and photo gallery). The second half day is spent at Saint Marcy Mercy Hospital, viewing cases done in the operating room and in interventional radiology guided by SMMH Director of Vascular Access, Holly Favero, RNP. It is hoped that dialysis personnel will gain a deeper understanding of dialysis access evaluation, planning, options, creation and maintenance (link to SMMH CEU brochure).

Presentations by Dr. Webb

I have been used to presenting talks on dialysis access since I first got into this field full time, and have a renewed commitment to outreach teaching this year. At this time there is a strong demand for my global dialysis access talk, which I have given a half dozen times over the last year and a half, and which I plan to give on a monthly basis until the demand is satisfied. CEUs and CME credits for these talks is now available through Saint Mary Mercy Hospital. This talk will be recorded, edited, and made available for future viewing.

Following this, a talk on "Dialysis Monitoring, Maintenance, Repair and Rescue" is planned next for the local and regional audience, as well as talks on technical aspects of fistula creation and advanced fistula techniques for surgeons.

Research and publication

Since the beginning of Michigan Vascular Access, PC, we have maintained fairly extensive and comprehensive records on most of our patients, and have an enviable ability to track those patients over time. A spreadsheet of our clinical contacts over the last 11 years has over 24.000 entries. Over 3500 individual patients have been seen in that time, and over 10,000 procedures. Complete cadres of patients are available for generating statistics about percentage of fistula maturation and time to maturation, requirement for secondary procedures and so forth. We have published some of these preliminary results in yearly newsletters, last covering our 2010 data. Our experience in basilic transposition (nearly 500 transpositions in the last 11 years by a single surgeon) may be untouchable, and should yield some important teachable points. MiDRE will be used to support the necessary efforts to compile the information and publish the results.

Our current data tracker Tina R is currently working to provide updates on existing statistics for fistula creation.

I am currently sorting through the nearly 6500 clinical and radiological images in our files to find the most characteristic and educational material available. Many additional clinical, ultrasound, and radiologic images in patient charts but not yet in the files are also available.