A novel factor for primary arteriovenous fistula failure: hyperinsulinism

Abstract

Introduction: Dysfunction of vascular access is an important reason of morbidity for dialysis patients and it is a major factor affecting the economical burden of hemodialysis. The preferred type of vascular access is creation of an arteriovenous fistula (AVF). However, the problem of fistula maturation rate is still a challenge. Herein, we tried to search the role of hyperinsulinism and insulin resistance as a new predictor of primary AVF failure (pAVFF) that may be a cause of intimal damage. Methods: We included 119 patients (73 male and 46 female) with a diagnosis of end-stage renal disease (ESRD) who had undergone an AVF operation by a vascular surgeon. The AVF was examined for presence of thrill on the first postoperative day. A successful cannulation with two fistula needles with a blood flow of 250 mL/min for at least one complete dialysis session, after 4 weeks of AVF surgery was defined as functioning access. Insulin resistance in our patients was determined by the standard homeostasis model assessment (homa-IR). A logistic-regression analysis was performed to investigate the independent factors related with pAVFF. Findings: Detection of pAVFF occurred in 27 (22.7%) patients. The presence of thrill, amount of daily proteinuria, insulin levels, homa-IR, and serum albumin levels were found to be significantly different between patients with fistula failure and those without pAVFF. The logistic-regression analysis of preoperative factors revealed the following OR (odds ratio) and 95% CI values: homa-IR 1.205 (1.063-1.366) (p ¼ 0.004), serum albumin 0.398 (0.178-0.892) (p ¼ 0.025), and the amount of daily proteinuria 1.307 (1.012-1.688) (p ¼ 0.041). Even after addition of the presence of postoperative thrill on AVF, which was a postoperative strong clinical factor to the analysis, mean homa-IR and mean serum albumin continued to be independent predictors of pAVFF. Discussion: Insulin resistance or hyperinsulinism may be a significant cause of pAVFF, which emphasizes the role of endothelium in fistula dysfunction.

The association of erythropoietin-stimulating agents and increased risk for AV-fistula dysfunction in hemodialysis patients. A retrospective analysis.

“…Other investigators showed that diabetic patients with AVF problems had a poorer homa-IR index (Homeostasis model assessment). Such metabolic disturbance may impair the vascular endothelium [7,31]. This is in line with the present study where the Cases with diabetic nephropathy had higher HbA1c values before intervention.…”

The association of erythropoietin-stimulating agents and increased risk for AV-fistula dysfunction in hemodialysis patients. A retrospective analysis

“…HD condition variables were strongly correlated to each other, so we chose to include only one -StKt/V associated with a worse metabolic control. Such metabolic disturbance may impair the vascular endothelium [11,43]. This is also in line with the present study where the Cases with diabetic nephropathy had higher HbA1c values before intervention, which thereafter improved and became similar to Controls.…”

Mid-term cumulative patency of fistula and PTFE grafts among hemodialysis patients: A retrospective, single-center study from Palestine

“…17 However, there is a wide variation in the primary failure rates in the literature, 22.7%-53.5%. [21][22][23][24] We attribute our low primary failure rates of AVF (7.1%) to the routine pre-operative vascular mapping in the vascular department, which agrees with the recommendations of previous studies. 25,26 There was a strong correlation between peripheral arterial disease (for both AVF and AVG) and insertion site (for AVF) with increased primary failure rates.…”