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INTRODUCTION

In recent decades, the healthcare industry has implemented programs to raise awareness of kidney disease as a significant public health problem. Current focus is on early disease management intended to slow the progression of chronic kidney disease (CKD) to end-stage kidney disease (ESKD), which requires hemodialysis or renal replacement therapy. As CKD advances to severe kidney damage, with low kidney function, treatment considerations include peritoneal dialysis, hemodialysis, and kidney transplant. As shown in Figure 1, more than 1 in 7, that is 15% of US adults or 37 million people, are estimated to have CKD. 1 As many as 9 in 10 adults with CKD do not know they have CKD. About 2 in 5 adults with severe CKD do not know they have CKD.

Figure 1 – United States Statistics for Adults with CKD

Source: Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States , 2021 Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2021. https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html. Accessed October 13, 2021.

As of August 2021, two United States Food and Drug Administration (FDA) cleared catheter-based devices are designed to create endovascular arteriovenous fistula (AVF) for hemodialysis management of ESKD. 2 Both are designed around the vascular anatomy in the proximal forearm, which requires preoperative assessment of the upper extremity vasculature using ultrasound mapping. One system is a single-catheter thermal resistance device that uses heat and pressure to fuse the arterial and venous wall to construct a percutaneous AVF between the proximal radial artery and perforating vein of the proximal forearm. 3 The other is a dual catheter-based system that uses radiofrequency energy to produce an anastomosis between the ulnar artery and adjacent ulnar vein in the proximal forearm or the radial artery and adjacent radial vein in the proximal forearm. 3 This educational activity will focus on providing a deeper understanding of the dual catheter system and reinforce the importance of accurately screening patients to determine suitability for endovascular (dual catheter system) AVF creation with this device. Healthcare Expenditures for Persons with CKD In the 2020 Annual Report of the United States Renal Data System , Medicare fee-for-services (FFS) cost for patients with CKD (excluding ESRD) exceeded $81 billion in 2018 and represented 22.3% of Medicare FFS spending. 4 Additionally in 2018, Medicare spending for patients with CKD (excluding ESRD) aged 66 and over exceeded $70 billion, accounting for 23.8% of all spending in the age group. 4 In comparison over the past 20 years, expenditures for CKD patient has increased at a higher rate than that of the general public or for patients with diabetes mellitus or heart failure. 4 Hemodialysis Access A shared decision-making process between the patient and providers determines an individualized ESKD Life-Plan and vascular access options. In the United States, hemodialysis is the most broadly used modality of kidney replacement therapy. 5 Patients with CKD preparing to start hemodialysis, transitioning from another kidney replacement treatment, failing/failed kidney transplant, or currently on hemodialysis with a failing arteriovenous (AV) access or hemodialysis catheter should be considered for hemodialysis vascular access. 5 The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines delineate the following key principles when considering vascular access locations and suitable vessels: 5 • Distal first to proximal next approach, • Always preserve the integrity of vessels for future vascular access options, and • Nondominant extremity is preferred to dominant, only if choices are equivalent.