Practical and ethical challenges of maintaining vascular access in chronic kidney disease: A qualitative interview study
Bibliographic record
Abstract
Objective Chronic kidney disease (CKD) affects 16.8% of adults in the United States for which hemodialysis is most commonly used for renal replacement therapy. Although emphasis with the Fistula First Initiative has historically focused on the prioritization of autogenous arteriovenous access, higher rates of maturation failure and access dysfunction have prompted a reappraisal of this approach in the literature and clinical practice. Oftentimes, frail or medically complex patients with dysfunctional access are subjected to a large number of surgical procedures to maintain or reestablish patency. The influence of arteriovenous fistula (AVF) dysfunction and repetitive reintervention on patient experience and quality of life remains largely unexplored in contemporary literature. Methods Using a provincial database of renal failure patients (PROMIS), we selected patients who had undergone 5 or more interventional procedures (open or endovascular) to maintain vascular access within a 20 year period from a single institution. Semi-structured interviews were conducted with these patients and analyzed qualitatively using the constant comparative approach. Results Seventeen patients who met the inclusion criteria were recruited from across British Columbia. The cohort included patients from both genders (10 male, 7 female) between the ages of 52-87 years old. Four major thematic categories were identified; treatment values, impact of disorder, disposition towards AVF and impact of repeated interventions. Survival was the primary theme in the ‘treatment values' category (11/17), with reduction in dialysis frequency being secondary. Within ‘impact of disorder', loss of independence was the primary theme (14/17) with psychological impact being secondary. Displeasure with the high rates of failure emerged as the primary theme (15/17) in ‘disposition towards AVF', with pain with use (8/17) and inadequate informed consent (8/17) as secondary themes. Finally, for ‘impact of repeated interventions', the primary theme was interruption to daily life (12/17). Overall, only 8/17 patients expressed satisfaction with their AVF. Conclusion These findings highlight that repeated interventions to maintain fistula patency pose significant disruption to patient's quality of life. Rates and impacts of fistula failure need to be thoroughly explained to patients during their informed consent process, moving towards a more patient-centered, individualized and holistic approach to vascular access over a ubiquitous ‘Fistula First' approach in all cases.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.020 | 0.030 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.013 | 0.014 |
| Scholarly communication | 0.006 | 0.005 |
| Open science | 0.002 | 0.007 |
| Research integrity | 0.002 | 0.005 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".