Construction Of An Autologous Arteriovenous Fistula Management Scheme For Patients With End-stage Renal Disease Before Dialysis

ObjectivesTo investigate the current situation of arteriovenous fistulas(AVF)use for the first time in patients with End stage renal disease(ESRD),Meta-analysis,crosssectional investigation,and qualitative study were performed.To explore the related factors affecting the use of AVF in ESRD patients for the first time on dialysis,and to find out the existing problems in the management of AVF in ESRD patients before dialysis.Two rounds of Delphi expert letter consultation were used to construct the management plan of pre-dialysis AVF in ESRD patients,which provided guidance and basis for the clinical standard of pre-dialysis AVF management in ESRD patients.MethodsPart 1:This part is divided into three parts(1)Meta analysis was used in the first part.Domestic and foreign literatures on the use of first dialysis AVF in ESRD patients were systematically searched,and singlegroup rate Meta-analysis was used to determine the use rate of first dialysis AVF in ESRD patients in China.(2)The second part adopts the cross-sectional survey method.A total of 203 patients who had undergone Maintenance hemodialysis(MHD)in the hemodialysis center of our hospital from August to November 2020 were selected.Through the data system and questionnaire survey of patients,the utilization rate of AVF first dialysis in ESRD patients was obtained.Logistic regression analysis was used to analyze the related factors affecting the use of AVF for the first dialysis in ESRD patients.(3)The third part adopts the phenomenological research method in qualitative research.With ESRD patients as the research object,a semi-structured interview was adopted.The interview was conducted around the interview outline,and the seven-step analysis of Colaizzi phenomenological data was used for data analysis to form the final theme.Part 2:Literature analysis was used in this stage.The system searched UPTODATE,BMJ Best Practice,UK National Institute for Health and Clinical Excellence(NICE),JBI Evidence-Based Healthcare Center Database,Medical Metone Guideline Network,US National Guideline Library,International Guideline Library,Ontario Association of Registered Nurses,Canada,and CochraneLibrary,PubMed,CNKI,VIP,Wanfang and other databases were used to search the guidelines,expert consensus and systematic evaluation related to AVF management from the database establishment to October 2020.The literature quality evaluation and evidence grading were carried out to summarize the best evidence of AVF management in ESRD patients before dialysis.Part 3:The Delphi expert letter consultation method is adopted in this stage.The measures related to the management of AVF in the best evidence of the management of pre-dialysis AVF in ESRD patients were summarized,and the preliminary draft of the management plan of pre-dialysis AVF in ESRD patients was developed.Sixteen kidney/hemodialysis experts from level-III hospitals were selected,and the letter inquiry form was sent to the experts after contacting with them.The experts rated the importance and operability of the items according to Likert5 scoring method,and added,deleted and modified the contents of the items,with reasons given.After the questionnaire is collected,the research team will collect,sort out and analyze the questionnaires to determine the next round of questionnaires.The inclusion criteria of indexes were the mean value of important assignment≥3.5,coefficient of variation<0.25.If there is only one agreement,the research group will decide whether to choose or not after discussion based on experts’ opinions,and finally establish the indicators for the second round of letter consultation.The authority and reliability of the results are indicated by the positive coefficient of experts,the degree of authority,the degree of concentration of expert opinions and the degree of coordination.ResultsPart 1:(1)In the Meta analysis,18 literatures were included,with a total sample size of 4738 patients,including 795 patients receiving AVF for the first time on dialysis.The combined value of the utilization rate of AVF for the first time in ESRD patients in China was 18.0%.(2)A total of 203 patients were investigated.The utilization rate of first dialysis AVF in ESRD patients was 24.63%.Logistic regression analysis showed that diabetic nephropathy and regular follow-up were the protective factors for the first use of AVF on dialysis.(3)A total of 14 ESRD patients were included for interviews,and three themes were finally extracted:diverse emotional experiences,positive cooperation and negative coping with the establishment of AVF,and lack of knowledge related to AVF.Patients have a strong desire to learn knowledge related to AVF.Part 2:By searching domestic and foreign databases,14 literatures,3 best practice information(volumes),3 clinical decisions,4 guidelines,1 expert consensus,and 3 systematic evaluations were included.The evidence collected from the retrieved literatures was summarized,and a total of 32 pieces of evidence were formed from three aspects,respectively as follows:Arteriovenous fistula in preparation(the patient’s early screening,assessment,health education of patients),the establishment of arteriovenous internal fistula(arteriovenous fistula in establishing timing,arteriovenous fistula in a place,way of vascular anastomosis,arteriovenous fistula in a note),arteriovenous fistula after the foundation of maintenance(arteriovenous fistula in monitoring,promote internal fistula after mature,complications,and treatment,health propaganda and education).Part 3:Through 2 rounds of Delphi expert letter consultation,the management plan of arteriovenous fistula before dialysis for end-stage renal disease patients was finally formed,including 3 first-level indicators,11 second-level indicators,and 34 third-level indicators.The effective recovery rate of the first round and the second round was 93.75%and 100%.The expert authority coefficient of the second round was 0.853 and 0.857,the coefficient of variation of item importance was 0-17%and 0-9%,and the Kendall harmony coefficient was 0.184 and 0.220,respectively,the difference was statistically significant(P<0.001).ConclusionsThe utilization rate of the first dialysis AVF in ESRD patients in China is still low,and the clinical management of the first dialysis AVF in ESRD patients is mostly a single form of health education.In this study,a management plan for predialysis AVF in ESRD patients was constructed according to China’s national conditions.The results of the letter consultation were scientific and reliable,which could provide a reference for the management of predialysis AVF in ESRD patients.