Medical director of Birmingham Heartlands Hospital Dr Hugh Rayner reminded delegates to the DOPPS session of Nephrology in Practice 2001 that DOPPS was a study in progress and a lot of the data being discussed at the session was the baseline description of the populations being studied

"There is clearly a lot more analysis of this enormous database that needs to be done and willl be done," he said.

"This presentation is designed to demonstrate what questions can be asked and to get some evidence behind our practice patterns where they have largely been built upon tradition and urban mythology.

"The biggest issue we have in the UK is getting fistulas created and getting them usable. We therefore rely on a large number of temporary catheters.

"If we had a more efficient way of creating fistulas and then using them, this would reduce the time period in which temporary access may be required."

However, in this country, the use of the fistula tended to be delayed because current practice cautioned that if you needled the fistula early, you might traumatise it, damage it and reduce its long-term survival, he explained.

"So, I was interested to see whether the DOPPS database could tell us whether this practice pattern was based on any real evidence," Hugh Rayner said.

His study attempted to identify factors related to the length of time until the AV fistula was first needled for those patients who were beginning dialysis with a fistula and them looked for any association between early needling and AV-fistula survival.

"There are large country differences in the use of AV fistulas at the start of haemodialysis," Hugh Rayner said.

"The UK is second only to the USA in the use of catheters as the first mode of dialysis access and we are by far the worst in Europe for getting fistulas ready in time.

"The usual time interval between referral to the surgeon and access placement in the UK is by far the worst in the whole world. We have 61% of units saying their usual time is greater than four weeks and that dwarfs any other country.

"In Germany, they get 51% done in less than or equal to a week. And if we wait at least four weeks to get it done, then we don't needle it for another four weeks, we've got an awful long time for temporary catheters to be in place and cause problems.

"On the other hand, we have a very low prevalence of grafts compared with the USA," he said.

The common excuse given for this situation was that there was not time to get a fistula done before the patient was dialysed because patients always presented as emergencies, he said.

"Yet, in the UK, we are better than Germany in getting patients to a nephrologist early -- or not too late -- and most of Europe is better than the USA. So, any differences seen in the UK cannot be simply explained by the fact that we are presented with a lot more renal emergencies," Hugh Rayner stressed.

The odds of starting dialysis with a fistula are increased two to three times if you can get a fistula created within three weeks of referral.

There were also huge differences in time to first needling of fistulas between countries, he continued.

"Italy has a mean needling time between surgery and first needling of 27 days. Ours is 90 days and in the US it's 102 days. It's interesting that the English speaking countries have similar practices, different from France, Italy and Germany," Hugh Rayner said.

Yet early needling practice did not seem to be associated with the co-morbidity factors that were tested in the study model. Nor did early needling seem to be chosen for any factors that could be predicted.

But the study did show that there was significantly greater risk of fistula failure if a patient had had a prior temporary access.

"This clearly is very important," Hugh Rayner continued.

"If we can avoid patients having temporary access, not only do they avoid all the complications of temporary access itself, they are also more likely to have a more long-lasting fistula when it is created.

"Avoiding temporary access seems to an all-round good idea," he stressed.

"Needling of fistulae within 28 days as currently practised by those countries where it is being done it does not prejudice fistula survival," Hugh Rayner continued.

"But I would not like people to get the idea that you should go ahead and try to needle every fistula within a week. This is a study of current practice that is going on in Europe and the USA.

"We've now got to go out to these countries and ask these people who are doing it how they do it. In the UK we can learn from our European colleagues.

"Fistula survival was significantly lower in those who had had a prior temporary access. Temporary dialysis catheters are bad news.

"They have complications of their own, they reduce your fistula survival, yet where needling is practised early it seems to be safe practice from the point of view of fistula survival.

"And if we can spread that practice around Europe into the English speaking countries we may reduce the need for temporary catheters.

"The two major issues so far coming out of DOPPS are dialysis dose and access. Dialysis dose in the UK at the moment is pretty equivalent to the rest of Europe, but access is our huge weakness and we've got to do something about it," Hugh Rayner concluded.

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