Arteriovenous Fistula Use Research Articles

Comments regarding ‘Vascular Access for Haemodialysis in Patients with Central Vein Thrombosis’

In a growing number of patients with renal failure, dialysis treatment is initiated with the use of central vein catheters. Despite guidelines recommending the use of arteriovenous fistulae, catheter dialysis with its inherent risk of sepsis and central vein obstruction (CVO) is still employed as vascular access. Jakimowicz and co-workers have addressed this issue and report on the treatment of catheter-induced CVO using a wide variety of surgical reconstructions. During a period of 20 years, a total number of 49 patients were operated, representing the largest published series ever. A mix group of patients with CVO was treated, including 16 patients with secondary procedures after access creation and 33 primary vascular access procedures. Prosthetic graft implantation with outflow to the subclavian, jugular, iliac and caval veins was employed with remarkable good outcome. Primary and secondary patency rates were 85 and 96% at one year, and 75 and 92% at 3 years of follow up, respectively. These are excellent results as compared to data from the literature. As far as can be deducted from the few reports on small patient groups the results of surgical reconstructions of mediastinal veins are better than those of interventional radiology. 3 These procedures, however, always mean major surgery. Therefore guidelines do advise endovascular intervention as a primary option for CVO. In this lies the main weakness of the present study. Endovascular intervention was not offered to the patients,

Determinants of vascular access: Patient characteristics or physician preference?

AbstractBACKGROUNDThe goal of the Fistula First Initiative is to increase the use of arteriovenous fistula (AVF) for dialysis to 66% of total dialysis patients. Most facilities fall short of this target. Our objective is to determine the impact of provider bias in influencing the rate of AVF in dialysis facilities.METHODSWe retrospectively studied 176 patients who received a new vascular access for dialysis over 18 months in two groups. In one group, a single surgeon was involved in vascular access placement (56 patients), while the other group had multiple surgeons (120 patients).RESULTSA significantly higher number of patients received AVF as their primary vascular access in the single‐surgeon group, even though there were no significant differences in age, gender, and co‐morbidities in the two groups. There was no difference in primary and secondary fistula failure rates.CONCLUSIONSOur study shows that AVF rate varies in different dialysis units, involving different providers, despite similar patient profiles. This implies the presence of a possible bias among providers when selecting a patient for type of access. Thus a higher rate of AVF placement, closer to the target rate, can be achieved by removing this bias. Dial. Transplant. © 2011 Wiley Periodicals, Inc.

Influence of diabetes and perivascular allogeneic endothelial cell implants on arteriovenous fistula remodeling

Arteriovenous fistula (AVF) is the preferred type of vascular access for hemodialysis to treat end-stage renal disease. A high proportion of AVF are never used for dialysis because the vein fails to mature adequately. We have previously described the safety and feasibility of Vascugel (Genzyme BioSurgery, Cambridge, Mass) (allogeneic aortic endothelial cells in a gelatin matrix) when placed around the anastomotic and venous outflow sites of AVFs (Vascular intimal Hyperplasia: Extending Arterial and venous patency, Limiting vascular Trauma, and inhibiting Hyperplasia while re-establishing vascular health [V-HEALTH] clinical study). In this retrospective analysis, we investigated factors that influenced AVF remodeling in patients from the V-HEALTH study. We hypothesized that providing healthy endothelial cells and their secreted factors immediately after surgery could enhance venous remodeling in the setting of vascular injury. Thirty-one AVF patients from the V-HEALTH study were randomized 2:1 to receive either Vascugel or control matrices (placebo) at surgery and were followed for 24 weeks. Venous lumen diameter was measured by ultrasound at 1, 3, and 5 cm from the anastomosis. Vein remodeling (change in lumen diameter at 4, 12, and 24 weeks compared with baseline diameter at 2 weeks) was analyzed using a multiple regression mixed model. The results indicated that diabetes was a significant, negative predictor of venous remodeling over the 24-week study (P = .02). The model-predicted change in lumen diameter from 2 to 24 weeks was -0.7 mm in diabetic patients (n = 11) and +2.4 mm in nondiabetic patients (n = 15), a difference of 3.1 mm, 95% confidence interval [CI] (1.4-4.9), P = .0014. Patient race, baseline vein diameter, and time post-AVF creation were also significant factors that affected remodeling (P < .05). Compared with placebo, there was a strong suggestion that Vascugel treatment improved the rate of venous enlargement in diabetic patients (P = .05). The model-predicted change in lumen diameter at 24 weeks was -1.9 mm for placebo-treated diabetic patients and +0.4 mm for Vascugel-treated diabetic patients, a difference of 2.3 mm, 95% CI (-0.1-4.8), P = .06, suggesting that treatment with Vascugel may mitigate the negative influence of diabetes on AVF remodeling. Diabetes negatively impacts AVF remodeling and targeted local therapy with perivascular, allogeneic endothelial cells may ameliorate this effect. A phase II trial designed specifically to evaluate AVF remodeling is needed to determine if Vascugel can increase AVF maturation and use and to support larger randomized trials.

Efficiency of the kidney disease outcomes quality initiative guidelines for preemptive vascular access in an academic setting

The National Kidney Foundation-Kidney Diseases Outcomes Quality Initiative (KDOQI) for vascular access guidelines state that patients with late-stage chronic kidney disease (CKD) should undergo native arteriovenous fistula (AVF) creation at least 6 months before anticipated start of hemodialysis (HD) treatments to obviate the need for other vascular access types, such as grafts or central catheters. The objective of this study was to determine the incidence of HD, the functional patency, and associated morbidity of AVFs in patients with late-stage CKD placed according to KDOQI. Consecutive patients with late-stage CKD who underwent AVF creation using KDOQI guidelines for anatomy between January 2003 and December 2007 at two tertiary academic centers were retrospectively evaluated. Baseline demographics, AVF type, and clinical comorbidities were recorded. Patients were stratified into one of four groups (groups A-D) over the follow-up course based on two end points: patency of their 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 (ie, death, refused hemodialysis, kidney transplant, or fistula failure; group D). Secondary outcomes were time to first cannulation, complications, and secondary interventions. AVFs were created (46% forearm and 54% upper arm) in 150 patients with CKD (85% men, median age 63 years old). At a median follow-up of 10 months, 74 patients (49%) were receiving HD and of these, 48 patients (65%) were using their AVF (group A), whereas 26 patients (35%) were not due to fistula failure (group C). Thirty-four patients (23%) never initiated HD treatments, but had a viable AVF (group B), and 42 patients (28%) never initiated HD and abandoned their AVF (group D). Overall, AVF abandonment was 51%. Mean maturation time of all AVFs successfully 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 AVFs was 19% and 27% at 6 and 12 months, respectively, with a mean number of two interventions per AVF (range, 1-10). Mortality during the study was 23%. Despite successful creation and maturation of a preemptive AVF in nearly two-thirds of patients who started HD during the follow-up and given the following observations: the high overall mortality of the population, the morbidity and costs in secondary procedures of AVF creation, and the high incidence of abandonment, it is unclear if this strategy would demonstrate a benefit in a randomized trial when compared to other access strategies.

Epidemiology of hemodialysis vascular access in the United States

Reemergence of the importance of vascular access in the care of the chronic hemodialysis patient has gained prominence due to renewed interest in clinical outcomes and evidence-based interventions. Further fueled by anticipated regulatory changes in the reimbursement for dialysis care in the United States by 2011 and beyond, the drive to improve quality of care for hemodialysis patients has identified vascular access issues as a key contributor to outcomes. Focus has shifted from simply providing any hemodialysis vascular access to a strong preference for the use of native arteriovenous fistulas and subsequently to a need for reducing exposure to central venous catheters. Combined, these goals have forced a reevaluation of the role of arteriovenous grafts. The context and events associated with the evolution of thinking on these issues as well as available data supporting them are discussed. The key leadership role of nephrologists is emphasized along with a summary of problems and proposed solutions.

Patient attitudes towards the arteriovenous fistula: a qualitative study on vascular access decision making

The use of arteriovenous fistulas (AVFs) among hemodialysis (HD) patients has been consistently associated with lower rates of morbidity and mortality; however, up to 30% of eligible patients refuse the creation or cannulation of an AVF. We aimed to understand the attitudes, beliefs, preferences and values of patients who refused creation or use of an AVF. With qualitative methodology, we conducted semi-structured interviews with 13 HD patients (Canada, 2009), who previously refused creation or use of an AVF. Three independent analysts reviewed interview transcripts. We discovered three main themes that impacted the decision to refuse a fistula: (i) poor previous personal or vicarious experiences with the fistula, including cannulation, bleeding, time commitment and appearance; (ii) knowledge transfer and informed decision making. Patients identified information from other patients to be as important as information from health care workers, that information on vascular access (VA) was presented but not understood and that timing of information was crucial with information overload at the start of dialysis and (iii) maintenance of status quo and outlook on life. Some patients stated they live day-to-day without being influenced by the mortality risks with a catheter. AVF refusal is multifactorial and depends on individual patients. Although nephrologists consider the fistula to be the optimal VA, patients do not think in the same terms of reducing infection rates but focus on the practical day-to-day use of their VA and its influence on their quality of life and future outlook.

Implementation of a predialysis pathway to increase arterio venous fistula use at the commencement of haemodialysis: the AHa-CARI vascular access implementation project

Aim: To increase utilization of arteriovenous fi stulae (AVF) at haemodialysiscommencement via implementation of a predialysis pathway.Background: Patients who commence haemodialysis with a AVF have lowermorbidity and mortality. AVF use at the fi rst dialysis remains unacceptably lowin Australasia.Methods: A multicentre, before-after study was conducted over 18 months.Interventions included implementation of a formalized pre-dialysis pathway, withemphasis on pre-dialysis patient education, and encouraging specifi c eGFRthresholds for vascular access (VA) referral (eGFR 20 ml/min) and placement(eGFR 15 ml/min). Logistic regression was used to assess the effect of the interventionon catheter use at commencement of haemodialysis.Results: Nine nephrology centres commenced 1013 patients during the study,323 in the baseline phase and 690 during the intervention phase. The proportionof patients receiving predialysis education was unchanged following the interventionphase (65% vs 64%, p = 0.83). eGFR at surgical review and VA placementrose signifi cantly (8.5 vs 10.6 a 8.1 vs 10.6 ml/min respectively, p l 0.001) butremained lower than predialysis pathway thresholds. The proportions commencingwith an AVF pre and post intervention were unchanged (40 vs 41%, p =0.86), with no change following adjustment for age, gender, late referral, centrea pre-dialysis education (OR 0.92, p = 0.58). Three of 9 centres demonstratedincreases in AVF use of 11, 15 a 20%, while 3 centres reduced AVF use between3 and 9%. No interaction was seen between treating centre and the interventionphase (all P g 0.05).Conclusions: Implementation of a predialysis pathway did not increase AVF useat fi rst dialysis but was associated with higher eGFR at access placement. Longerand multifaceted interventions are more likely to be effective in increasing AVFusage at fi rst dialysis.

Developing Recommendations for Vascular Access for Hemodialysis: Vascular Access Working Group of the Italian Society of Nephrology

This paper presents an overview of the project carried out by the Vascular Access (VA) Working Group of the Italian Society of Nephrology with the aim of developing 4 position papers at the national level on how to choose, use, and implant the different, possible types of vascular access. The topics of the project are: 1) recommendations on the use of prosthetic arteriovenous fistulas for vascular access in hemodialysis, 2) recommendations on the use of venous catheters for hemodialysis, 3) infections induced by a venous catheter for hemodialysis, and 4) how to create and maintain a vascular access for hemodialysis. This paper also gives an explanation of the difficulties existing in Italy in the implementation of international guidelines, mostly due to significant differences in the procedures for the creation of VA, compared with the countries where most of the literature on the subject has been published. Individual position papers were drafted for each of the different topics. A list of recommendations was produced based on existing guidelines. Then these recommendations were critically reviewed by experts working in Italy, who expressed their opinion on their inclusion in position papers. The working method used to gather the opinions of the various experts is described. The final target is to provide clinicians interested in VA with updated documents on selected topics. Such documents will be updated periodically, and they will present a thorough overview of expert opinions.

Creating functional autogenous vascular access in older patients

Arteriovenous fistulas (AVFs) are the preferred choice for hemodialysis vascular access (AV access); however, there is debate over the utility of AVFs in older patients, particularly concerning access maturation and functionality. We reviewed our AV access experience in patients ≥65 years of age. We analyzed consecutive AV access patients ≥65 years old with access operations between March 2003 and December 2009. All patients had ultrasound vessel mapping. In addition to overall outcomes review, the data for patients ≥65 years old were stratified into three 10-year increments by age for further analysis. We compared functional patency data for our older patients with those of our non-elderly patients aged 21 to 64 years treated during the same time period. Four hundred sixty-one consecutive AV access patients new to our practice were included in this study. Ages were 65 to 94 years (mean, 73 years). Two hundred thirty-six (51.2%) were female, 276 (59.9%) patients were diabetic, and 103 (22.3%) were obese. One hundred seven (23.2%) patients had previous access operations. Radiocephalic AVFs were constructed in 29 (6.3%) patients, 99 (21.5%) patients had brachial artery inflow AVFs, 330 (71.6%) had proximal radial artery AVFs, and three were based on the femoral artery. Transposition AVFs were used in 124 (26.9%) patients. No grafts were used for AV access in any patient during the study period. Time to AVF use was 0.5 to 6 months (mean, 1.5 months). Primary, primary assisted, and cumulative patency for patients aged 65 to 94 years were 59.9%, 93.7%, and 96.9% at 12 months and 45.3%, 90.1%, and 94.6% at 24 months, respectively. Follow-up was 1.5 to 77 months (mean, 17.0 months). Subgroup age stratification (65-74 [n = 268], 75-84 [n = 167], 85-94 [n = 26] years) found no statistical difference in functional access outcomes. Primary, primary assisted, and cumulative patency rates were not statistically different in the elderly and non-elderly populations (P = .29, .27, and .37, respectively). One hundred fifty-six patients died during the study period, 1.3 to 61 months (mean, 20 months) after access creation. No deaths were related to access operations. AVFs are feasible and offer functional and timely AV access in older patients. There was no difference in functional access outcomes for older patients with subgroup age stratification. AVF patency rates were not statistically different in the elderly and non-elderly populations. Cumulative AVF patency for patients ≥65 years of age was 96.9% at 12 months and 94.6% at 24 months.

Achieving the Goal of the Fistula First Breakthrough Initiative for Prevalent Maintenance Hemodialysis Patients

The Centers for Medicare & Medicaid Services (CMS) established a national goal of 66% arteriovenous fistula (AVF) use in prevalent hemodialysis (HD) patients for the current Fistula First Breakthrough Initiative. The feasibility of achieving the goal has been debated. We examined contemporary patterns of AVF use in prevalent patients to assess the potential for attaining the goal by dialysis facilities and their associated End-Stage Renal Disease Networks in the United States. Observational study. US dialysis facilities with a mean HD patient census of 10 or more during the 40-month study period, January 2007-April 2010. Mean changes in facility-level AVF use and percentage of facilities achieving the 66% prevalent AVF goal within the United States and each network. Mean prevalent AVF use within dialysis facilities increased from 45.3% to 55.5% (P < 0.001) in the United States, but varied substantially across regions. The percentage of facilities achieving the 66% AVF use goal increased from 6.4% to 19.0% (P < 0.001). During the 40 months, 35.9% of facilities achieved the CMS goal for at least 1 month. On average, these facilities sustained mean use ≥66% for 12.9 ± 11.7 (SD) months. Case-mix and other facility characteristics explained 20% of the variation in proportion of facility patients using an AVF in the last measured month, leaving substantial unexplained variability. This analysis is limited by the absence of facility case-mix data over time, and the national scope of the initiative precludes use of a comparison group. Achieving the CMS goal of 66% prevalent AVF use is feasible for individual dialysis facilities. There is a need to decrease regional variation before the CMS goal can be fully realized for US HD facilities.

Preventing catheter-related infections in children undergoing hemodialysis

The increased use of tunneled cuffed catheters in children on chronic hemodialysis is the result of their relative ease of insertion, pain-free dialysis and immediate use. The disadvantage of their use is that they are associated with catheter-related bacteremia (CRB), which in turn is related with increased morbidity, access loss and occasionally metastatic infections and even death. A CRB might be difficult to diagnose and is often associated with a previous history of CRB, exit-site infection, low serum albumin and long duration of catheter use. There is evidence that the use of arteriovenous fistulae is associated with lower infection rates. The implementation of effective strategies for the prevention of CRBs include the adoption of policies for improving arteriovenous fistula rates, appropriate surgical catheter insertion and optimal nursing care of the exit site, and a safe connection technique. Recently, the effectiveness of antimicrobial catheter solutions for preventing CRB has been documented in a number of randomized clinical trials. In addition, the application of antibiotic ointments at the exit sites of tunneled cuffed catheters might be significant for the reduction of Staphylococcus-related CRB. The upside is that education-based programs combining specific preventive measures can significantly reduce CRBs.

Hemodialysis Vascular Access Training and Practices Are Key to Improved Access Outcomes

Recognizing that autologous arteriovenous fistula use was associated with improved outcomes in hemodialysis patients, the 1997 Dialysis Outcomes Quality Initiative (DOQI) vascular access practice guidelines from the National Kidney Foundation stressed fistulas as the optimal means of dialysis vascular access. In the United States, this emphasis has continued with the Fistula First Breakthrough Initiative. Much of the data supporting fistulas for dialysis access are derived from longitudinal cohorts, including the Dialysis Outcomes and Practice Patterns Study (DOPPS), dialysis provider databases, and other sources. This article reviews major findings from these data sources, focusing on specific practices and characteristics associated with greater arteriovenous fistula use in dialysis facilities worldwide. Important and often overlooked characteristics that are discussed in detail include specific preferences of dialysis staff regarding access type and the emphasis placed on fistula primacy and the number of fistulas created during surgical training. For example, in the DOPPS, the risk of initial fistula failure was 34% lower when fistulas were placed by surgeons who had created at least 25 fistulas during training (P = 0.002). It is imperative that dialysis clinicians advocate actively for specific dialysis access types on behalf of individual patients. Vascular surgery teaching programs must supervise adequate numbers of fistula procedures for every trainee.

Processes of Care and Reduced Mortality among Hemodialysis Patients in the United States

A major accomplishment of clinical nephrology during the past 15 years has been the substantial improvement in the quality of ESRD care. The proportion of underdialyzed patients in the United States was reduced from >60 to <10% of hemodialysis (HD) patients (1) (www.cms.gov/CPMProject/). Additional improvements have been observed during the past decade in the use of arteriovenous fistulas (AVFs) (2). In turn, better HD care has been associated with decreasing mortality among both prevalent and incident patients with ESRD (3). The association between temporal trends in mortality and better care persists after accounting for changes in other case-mix factors, and Wolfe et al. (4) showed that each 10% increase in the proportion of patients who received adequate HD was associated with a 2.2% decrease in case mix–adjusted mortality rates. These observations about improved quality of care and reduced mortality reflect information provided by a comprehensive, population-based ESRD surveillance system and national registry, composed of 18 regional Networks and the US Renal Data System (5). This surveillance system routinely collects, analyzes, and disseminates information about the occurrence, treatment, and outcomes of ESRD in the US population. The information is used to plan, implement, and evaluate interventions to reduce the occurrence and improve outcomes of individuals with ESRD. Examples of quality improvement interventions are those conducted by the ESRD Networks. The Networks use continuous quality improvement (CQI) to foster transfer and adoption of evidence-based HD practices (6) by ESRD treatment facilities (7). These CQI interventions have been shown to contribute independently to improved care (8,9). This system of data-driven, patient-oriented quality improvement predates …

The D&amp;T report

The D&amp;T report

La ética de las decisiones: catéter o fístula arteriovenosa interna

Given the clinical characteristics of incident and prevalent patients in current hemodialysis programs, the successful use of internal arteriovenous fistulas (IAVF) to provide permanent vascular access is increasingly difficult. This difficulty seems to be the cause of the increase in the number of permanent catheters detected in almost all periodic hemodialysis programs. Compliance with the recommendations of the various “guidelines” does not seem to be feasible, indicating the need not only to reconsider our final objectives but also the indications for this technique. Thus, at the present moment, IAVF are no longer the first choice of vascular access for extracorporeal therapy in some patients. Furthermore, the ethical dilemma no longer lies in the choice between a fistula or a catheter but rather in whether to give the choice of access to the patient and/or the patient's relatives, individually tailoring the distinct types of access, but without forgetting the obligation to improve our results both in terms of the choice of materials and in placement of devices, as well as in terms of the care and maintenance of vascular access devices. Time is showing us that catheters are the best – or only – vascular access option for an increasing number of patients, obliging us to significantly improve the results currently reported in most publications.

Routine Preoperative Vascular Ultrasound Improves Patency and Use of Arteriovenous Fistulas for Hemodialysis

Arteriovenous fistulas (AVFs) are the preferred vascular access for hemodialysis but have a considerable failure rate. This study investigated whether routine preoperative vascular ultrasound results in better AVF outcome than physical examination. Patients with end-stage kidney disease referred for permanent access formation were assessed by independent examiners using physical examination and ultrasound. After random allocation, the ultrasound report was disclosed to the surgeon for patients in the ultrasound group but not for the clinical group. End points were AVF failure and survival rates, analyzed by intention to treat and by use for hemodialysis. AVFs were made in 208 of 218 randomized patients. Clinical and ultrasound groups were similar in terms of patient characteristics, allocation to individual surgeons, and proportion of forearm AVFs. The ultrasound group had a significantly lower rate of immediate failure (4% versus 11%, P = 0.028) and, among failed AVFs, less thrombosis (38% versus 67%, P = 0.029). Primary AVF survival at 1 year was not statistically different (ultrasound = 65%, clinical = 56%, P = 0.081). Assisted primary AVF survival at 1 year was significantly better for the ultrasound group (80% versus 65%, P = 0.012). The number of patients requiring preoperative ultrasound to prevent one AVF failure was 12. Routine preoperative vascular ultrasound in addition to clinical assessment improves AVF outcomes in terms of patency and use for dialysis. National Research Register, United Kingdom, trial number N0046131432.

Arteriovenous Fistulas among Incident Hemodialysis Patients in Department of Defense and Veterans Affairs Facilities

A higher proportion of patients initiate hemodialysis (HD) with an arteriovenous fistula (AVF) in countries with universal health care systems compared with the United States. Because federally sponsored national health care organizations in the United States, such as the Department of Veterans Affairs (DVA) and the Department of Defense (DoD), are similar to a universal health care model, we studied AVF use within these organizations. We used the US Renal Data System database to perform a cross-sectional analysis of patients who initiated HD between 2005 and 2006. Patients who received predialysis nephrology care had 10-fold greater odds of initiating dialysis with an AVF (adjusted odds ratio [aOR] 10.3; 95% confidence interval [CI] 9.6 to 11.1). DVA/DoD insurance also independently associated with initiating HD with an AVF (aOR 1.4; 95% CI 1.2 to 1.5). Fewer patients initiated HD at a DoD facility, but these patients were also approximately twice as likely to use an AVF (aOR 2.3; 95% CI 1.2 to 4.6). In conclusion, patients in DVA/DoD systems are significantly more likely to use an AVF at initiation of HD than patients with other insurance types, including Medicare. Further study of these federal systems may identify practices that could improve processes of care across health care systems to increase the number of patients who initiate HD with an AVF.

Geographic Concentration of Poverty and Arteriovenous Fistula Use among ESRD Patients

There is substantial geographic variability in both incident and prevalent arteriovenous fistula (AVF) use among patients with ESRD. This study examined the degree to which these variations associate with poverty in the county of a patient's treatment center. We performed a cross-sectional study including 28,135 patients treated by 1127 hemodialysis centers in five ESRD networks (16 states) between June 1, 2005 and May 31, 2006. We used the 2000 U.S. Census to categorize county-level poverty and ascertained incident AVF use from the Medicare CMS 2728 form. We calculated the 30-month slope of change in AVF prevalence from monthly facility reports collected between 2003 and 2005. More than 33% of treatment centers were located in high-poverty counties. County poverty inversely associated with incident AVF use (P for trend = 0.001). In contrast, substantial increases in prevalent AVF rates from 30.9 to 38.6% (P < 0.001) among treatment centers did not associate with county poverty (P = 0.9519). In conclusion, the concentration of poverty in the county where a treatment is located associates with incident AVF use by patients with ESRD but not with subsequent improvement in AVF use among prevalent patients. These results suggest that the Medicare ESRD program may mitigate poverty effects on AVF use.

Racial and Gender Differences in Arteriovenous Fistula Use among Incident Hemodialysis Patients

Background: Arteriovenous fistula (AVF) use is reported to differ among racial and gender groups. We sought to identify risk factors associated with incident AVF and whether racial and gender differences in AVF use persist after controlling for these factors. Methods: We evaluated 28,712 incident adult hemodialysis patients (age ≧18) from five ESRD networks starting dialysis between June 1, 2005 and May 31, 2006. Data were obtained from the Center for Medicaid and Medicare Services 2728 form. Results: Incident AVF use was reported for 11% of black and 12% of white patients [OR = 0.89 (95% CI: 0.83, 0.96)], and for 9% of females and 13% of males [OR = 0.66 (0.62–0.71)]. After adjusting for facility clustering, blacks were as likely as whites to use an AVF [OR = 1.00 (0.92–1.09)], while gender differences persisted [OR = 0.64 (0.59–0.69)]. Compared to patients with no renal care prior to dialysis initiation, incident AVF use was 16-fold greater among those with ≧12 months of nephrology care [OR = 15.99 (13.25–19.29)], 9-fold greater among those with 6–12 months of care [OR = 9.00 (7.45–10.88)] and 7-fold greater among those with at least 6 months of care [OR = 7.13 (5.73–8.88)]. Conclusion: Racial, but not gender, differences in incident AVF use were eliminated after accounting for clustering within facilities.

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

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.