Proposed Topic (Most preferred): :
Research and Innovations (new projects / technology / innovations / service models)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Authors (including presenting author) :
Au ILY(1), Leung AKP(1), Chak WL(2), Chan KS(3), Chan ACM(1)
Affiliation :
(1) Physiotherapy Department, Queen Elizabeth Hospital
(2) Department of Medicine, Renal Team, Queen Elizabeth Hospital
(3) Department of Surgery, Queen Elizabeth Hospital
Introduction :
Chronic kidney disease (CKD) is a global health burden. The incident rate of End-Stage Renal Disease (ESRD) in Hong Kong is 184 new cases per million populations (Renal Registry statistic 2023). Hemodialysis (HD) is one of the renal replacement therapies for ESRD. Vascular accesses, including central venous catheter, arteriovenous graft and arteriovenous fistula (AVF) are needed for hemodialysis. AVF traditionally provides the best clinical outcomes, including fewer vascular complications, less infections, lower hospitalization rate and mortality risk with longest patency rate.
AVF maturation is defined as an adequate vessel conduit size, with sufficient blood flow of autogenous anastomosis. Failure to maturation can occur due to vascular stenosis, thrombosis, and AVF dysfunction after surgery. Arm exercise training could promote AVF maturation, while other physical factors could affect AVF maturation. However, an optimal training program is not yet established in our locality.
Hence, a physiotherapy program was piloted in Queen Elizabeth Hospital (QEH) starting July 2023.
Objectives :
To review the effectiveness of the pilot Physiotherapy program on AVF maturation and physical outcomes in patients with ESRD after AVF creation in QEH.
Methodology :
This is a longitudinal case cohort series. Two patients (A: 54-year-old male; B: 59-year-old female) with ESRD completed at least 3 months of bi-weekly supervised preoperative and postoperative Physiotherapy program. It included individualized assessment, strengthening exercises on biceps, wrist flexors and handgrip according to international guidelines, 30-minute aerobic exercise training and a daily home strengthening exercise program.
Successful AVF maturation was determined by the doctor-in-charge at outpatient follow-up using ultrasonographic and clinical maturation examination criteria. Handgrip strength (HGS) and appendicular skeletal muscle mass index were measured at the preoperative and 8-week postoperative period. Kidney disease quality of life-36 (KDQOL-36) questionnaire was assessed at the preoperative period and upon completion of the program.
Result & Outcome :
AVF maturation was achieved in both patients with sufficient anastomosis diameter (A: 5mm, B: 6.7mm), increased forearm cephalic vein diameter (A: from “no sizable” to 6mm; B: from 1.4mm to 6mm) and increased radial artery diameter (B: from 2.3mm to 5.7mm). Improvement in HGS from 29.0kg-f to 33.0kg-f in A and 18.7kg-f to 19.6kg-f in B, and appendicular skeletal muscle mass index from 7.67kg/m2 to 8.15kg/m2 in A and 6.33kg/m2 to 6.62kg/m2 in B were observed. For KDQOL-36, both patients showed improvement in SF-12 physical composite score from 42.28 to 51.26 in A and 48.03 to 54.72 in B, while improvement in SF-12 mental composite score was demonstrated in one patient only (A: 60.09 to 57.72; B: 45.09 to 53.49).
Our case series demonstrated that the Physiotherapy program may facilitate AVF maturation and physical outcomes in patients with CKD after AVF creation. Further implementation in our ESRD patients is warranted.
