Efficiency of the KDOQI Guidelines for Vascular Access in an Academic Setting

Abstract

Background: The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (KDOQI) for Vascular Access guidelines state that late-stage chronic kidney disease (CKD) patients should undergo native arteriovenous fistula (AVF) creation at least 6 months before the anticipated start of hemodialysis (HD) treatments to obviate the need for other vascular access types. The objective was to determine the incidence of HD, the functional patency, and associated morbidity of AVFs in late-stage CKD patients placed according to KDOQI. Methods: Consecutive patients with late-stage CKD who underwent “first-time” index AVF creation using K/DOQI guidelines for anatomy between January 2003 and December 2007 at three tertiary academic centers were retrospectively evaluated. Baseline demographics, index AVF type, and clinical comorbidities were recorded. Patients were stratified into one of four groups (A-D) over the follow-up course based on the patency of their index AVF and whether or not they began HD. The ideal primary outcome was AVF maturation and use for HD (group A; cumulative functional patency). Other outcomes included AVF patency but no HD (group B), HD with AVF failure (group C), or no HD and AVF abandonment (group D). Secondary end points were time to first cannulation, complications, and secondary interventions. Results: Index AVFs were created (46% forearm and 54% upper arm) in 150 CKD patients (85% male; median age, 63 years). At a median follow-up of 10 months, 74 patients (49%) were receiving HD and 48 (65%) were using their index AVF (group A), while 26 (35%) were not (group C). Thirty-four patients (23%) never initiated HD treatments, but had a viable AVF. AVF abandonment was 51%. Mean maturation time of all index AVFs that were cannulated was 285 days (range, 30-1265 days). Complications encountered were maturation failure for cannulation (15%), focal stenosis requiring intervention (13%), inadequate flows on HD (9%), steal syndrome (9%), and thrombosis (8%). Cumulative functional patency for all index AVFs was 19% at 6 months and 27% at 12 months, with a mean number of two interventions per AVF (range, 1-10). Mortality for the group during the study was 23%. Conclusion: AVF creation in late-stage CKD patients has sobering results. This calls into question the wisdom of early AVF planning in this population.