Haemodialysis vascular access: current practices amongst Indian nephrologists

Introduction: Despite the growing number of haemodialysis (HD) patients in India, little is known about vascular access practice. We investigated the use and cost of different vascular accesses by Indian nephrologists. Methods: An online survey was emailed to 920 Indian nephrologists and 388 (42.1%) responded; 98.5% of whom were responsible for managing dialysis patients, 98% in hospitals. Results: Sixty-four percent of patients initiated renal replacement therapy with HD, 7% with peritoneal dialysis, 10% kidney transplantation and 19% conservative care. Forty-eight percent of patients were self-paying, 26% had employee reimbursement and 23% had insurance. According to 59% of responders, more than three-quarters of patients started dialysis with uncuffed catheter, less than one-quarter started dialysis with fistula; and very few used grafts or tunnelled catheters. Among prevalent HD patients, over half were dialysing with fistula (79% nephrologists), rather than uncuffed catheters (15% nephrologists) or grafts (<1% nephrologists). Sixteen percent reported at least one catheter-related sepsis in more than half of patients. Placement of uncuffed catheters cost US$160 in 92% facilities, whereas tunnelled catheters cost US$320 in 46% of facilities. An arteriovenous fistula (AVF) could be created for US$160 in 40%, and US$320 in 90% of centres. Thirty-five percent of nephrologists reported that grafts were not placed at their institute and where they were available, the average cost was over US$480. Forty-six percent of nephrologists had access to pre-dialysis clinics, <30% to vascular access programmes, and <17% conducted regular vascular access audits. Conclusions: The survey provides a snapshot of the current status of vascular access care in HD patients and highlights need for pre-dialysis clinics, vascular access services and registry audits.