Delays in establishing permanent vascular access and referring new hemodialysis patients to a nephrologist: A single center study.

Abstract

Objective: To determine the frequency and causes of delayed nephrology referral and late vascular access creation in newly initiated hemodialysis (HD) patients at a tertiary care center in Peshawar, Pakistan. Study Design: Descriptive Cross-sectional study. Setting: Department of Nephrology, Lady Reading Hospital, Peshawar. Period: January 2025 to June 2025. Methods: A total of 248 adult patients with end-stage renal disease (ESRD) initiating maintenance HD were enrolled. Data regarding demographics, comorbidities, timing of nephrology referral, counseling for vascular access, type of vascular access at initiation, duration of delay, and patient-reported reasons for delay were collected. Delay in permanent vascular access creation was categorized as no delay, 1–3 months, 4–6 months, or more than 6 months. Data were analyzed using SPSS version 25, with Chi-square tests applied for categorical variables. Results: The mean age of patients was 52.6 ± 13.4 years, with 57.3% males. Hypertension (75.8%) and diabetes mellitus (53.2%) were the most common comorbidities. Diabetic nephropathy (35.5%) and hypertension (25.0%) were the leading causes of ESRD. At HD initiation, non-tunneled central venous catheters (ntCVC) were used in 49.2% of patients, arteriovenous fistulas (AVF) in 33.9%, tunneled CVCs (tCVC) in 16.5%, and arteriovenous grafts (AVG) in 0.4%. Only 21.0% of patients had no delay in permanent vascular access creation, whereas 31.5%, 25.0%, and 22.5% experienced delays of 1–3 months, 4–6 months, and more than 6 months, respectively. The most frequently reported patient-related reasons for delay were financial burden (26.6%), lack of awareness (23.4%), fear of pain (19.4%), denial of disease (16.1%), and family refusal (14.5%). Conclusion: A catheter-first approach predominates among incident HD patients, with substantial delays in establishing permanent vascular access. Both patient- and system-level factors contribute to these delays, emphasizing the need for early CKD detection, timely nephrology referral, structured pre-dialysis counseling, and streamlined vascular access pathways to improve outcomes.