Background: Key anatomical factors mean that individuals needing arteriovenous access are unique and have different possibilities for fistula creation. The aim of this article is to describe a new classification system for all patients needing haemodialysis vascular access in the upper extremity with the purpose to simplify sharing the information about suitability for surgical access creation depending on vascular anatomy. Methods: According to the patient’s vascular anatomy in right and left superior extremities, patients were separated into three arteriovenous access stages (AVAS). The AVAS was validated by three blinded observers using a sample of 70 upper limb arteriovenous maps that were performed using ultrasound on patients referred for vascular access assessment. A sample size calculation was performed and calculated that for three observers, a minimum of 67 maps were required to confirm significant agreement at a Kappa value of 0.9 (95% confidence interval 0.75–0.99). Results: The Kappa value for inter-rater reliability using Fleiss’ Kappa coefficient was 0.94 and all patients fitted into the AVAS classification system. Conclusion: The AVAS classification system is a simplified way to share information about vascular access options based on a patient’s vascular anatomy with high inter-rater reliability.

Background: Whether patients commence haemodialysis with a central venous catheter (CVC), or an arteriovenous fistula (AVF) is used to audit the quality of a vascular access service. However, this crude metric of measurement can miss the increasing nuance and complexity of vascular access planning. We aimed to understand whether commencing haemodialysis with a CVC represented an ‘optimal’ or ‘suboptimal’ outcome and how this could influence the assessment of a vascular access service. Methods: From a prospective clinical database, patients known to nephrology >90 days prior to initiating haemodialysis as first-ever renal replacement therapy (2011–2020) from a single centre were included. Results: A total of 158/254 patients started haemodialysis with a CVC, and 96 with arteriovenous fistula. For 91 patients, the CVC was deemed ‘optimal’ care due to factors such as unpredictable deterioration in renal function (n = 41) and inadequate veins for AVF creation (n = 24). For 67 patients, the CVC was ‘suboptimal’ due to factors such as no/late referral to access assessment (n = 25) and delays in the AVF creation pathway (n = 13). There was no difference in mean survival between the AVF and ‘suboptimal’ groups (2.53 vs. 2.21 years, p = 0.31). There was a survival difference between AVF versus CVC (2.53 vs. 1.97 years, p = 0.002) and ‘suboptimal’ versus ‘optimal’ CVC cohorts (2.21 vs. 1.40 years, p = 0.16). Conclusions: Understanding whether a CVC is ‘optimal’ or ‘suboptimal’ allows a more nuanced analysis of service provision. High mortality in the ‘optimal’ group suggests a frailer cohort where CVC is potentially the best care. Studying ‘suboptimal’ CVC starts helps identify practice and system issues preventing ‘optimal’ care.

Acute kidney injury (AKI) requiring intermittent haemodialysis (AKI-IHD) is associated with significant morbidity and high mortality. There is limited data regarding clinical outcomes in individuals with AKI-IHD in Northern Ireland. The aim of this study was to explore clinical outcomes in a cohort of individuals with AKI-IHD, including rates of recovery to self-sustaining kidney function, mortality rates at 30 days and 2 years from start of haemodialysis, and to investigate potential predictors of these key outcomes. The Acute Haemodialysis Unit in the Royal Victoria Hospital, Belfast, Northern Ireland, was established in 2011 to provide onsite inpatient intermittent haemodialysis (IHD) to individuals requiring this supportive treatment. A retrospective review of 188 incident IHD patients in the Royal Victoria Hospital from January 2018-December 2022 was undertaken. Demographic and clinical outcome information on 12th May 2023 was obtained from the nephrology electronic database eMed (Mediqal) and the Northern Ireland Electronic Care Record. 188 individuals commenced IHD for the first time as a consequence of life-threatening complications of AKI during the 5-year period (January 2018-December 2022).75% of these patients were not previously known to the nephrology service, (GROUP A, n=142, mean age 63 years, mean baseline serum creatinine 99 μmol/L) while 25% (GROUP B, n=46, mean age 67 years, mean baseline creatinine 278 μmol/L) had been attending a Nephrology Clinic for at least 12 months.A significant proportion of AKI developed during the inpatient admission rather than at initial presentation (GROUP A 47%, GROUP B 50%).92% of GROUP A recovered self-sustaining kidney function before discharge, compared to 59% of GROUP B. A lower baseline serum creatinine was the only predictor of kidney recovery in GROUP B, p value=0.02. No predictors for kidney recovery were identified in GROUP A.The diagnosis of either AKI and/or dialysis was documented in 80% of electronic discharge letters for patients in GROUP A but only 54% of letters for patients in GROUP B.The 30-day mortality (from IHD start) in GROUPA was 14% compared to 9% in GROUP B. Individuals with a diagnosis of heart failure were four times more likely to die before discharge (p value=0.02) and those aged ≥ 70 years twice as likely to die before discharge (p value=0.049). The two-year mortality rate in the two groups was similar (GROUP A 35% vs. GROUP B 37%) despite GROUP B being significantly older. In this cohort of individuals with AKI-IHD, managed in the Royal Victoria Hospital, Belfast, the majority recovered self-sustaining kidney function.The mortality rates at 30 days were lower than reported in the literature and may be due to careful patient selection. The poorer outcomes associated with AKI-IHD support and a concomitant diagnosis of heart failure or age ≥ 70 years (or both) are useful in guiding clinical and patient expectations and decision making.