Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients

Abstract

Background: Most guidelines recommend the creation of arteriovenous fistula (AVF) in patients with chronic kidney disease (CKD) stage 4. However, an increasing number of studies suggest that early AVF creation leads to high rates of AVF failure and death before dialysis commencement. Only the Japanese guideline recommends AVF creation at CKD stage 5; however, no data are available regarding access-related outcomes at this stage. Method: This was a multicenter cohort study involving Japanese CKD stage 5 patients who underwent preemptive AVF creation from 2009 to 2013. The primary outcome was unnecessary AVF creation, defined as death before requiring dialysis or AVF failure before dialysis commencement. The secondary outcome was dialysis commencement. The associations with candidate predictors and the outcomes were examined. Results: A total of 303 patients were registered. Four cases of death before dialysis and 13 cases of AVF failure before dialysis commencement were observed. A total of 283 patients who advanced to dialysis were found to have functional AVFs. The cumulative incidences of unnecessary AVF creation and dialysis commencement at 1 year were 4.8 and 89.3%, respectively. Competing risk regression analyses showed that age ≥75 years (subhazard ratio [SHR] 3.12, 95% CI 1.20-8.09) and female gender (SHR 3.31, 95% CI 1.20-9.09) were associated with unnecessary AVF creation. Conclusions: A low incidence of unnecessary AVF creation was revealed among Japanese patients who received AVF at CKD stage 5. These results may help clarify the natural history of unnecessary AVF creation for other countries reformatting their guidelines regarding late vascular access creation.

Factors Associated with Dialysis Initiation in Patients with Predialysis Arteriovenous Fistula

“…The median eGFR at the time of AVF creation was 8.1 mL/min/ 1.73 m 2 in this cohort below the recommended window. Our observations were consistent with previous studies from Canada, Japan, and Australia which reported that incident fistula creations were performed between an eGFR of 7 and 14 mL/min per 1.73 m 2 [5,9,13,14]. This disparity may be attributable to several barriers: delay in referral from a nephrologist, lack of patient education, restricted local resources, and reimbursement policies.…”

“…The present study analyzed the clinical outcomes of the patients undergoing predialysis vascular access creation and explored the effects of clinical characteristics at surgery on the likelihood of initiating dialysis during follow-up. We found the majority of patients have predialysis AVF created later than recommended by national guidelines, and a large proportion of patients (91.7%) started hemodialysis within 1 year after AVF surgery, similar to that in a Japanese study [9]. Of the patients who started hemodialysis within 1 year, only 66.5% used AVF on their first hemodialysis session.…”

“…eGFR itself has been considered as a relatively poor predictor of the future need for dialysis in a previous study [15]. A study from Japan revealed dialysis commencement was associated with eGFR <10 mL/min/1.73 m 2 and hypertension [9]. However, in our study, eGFR and cystatin C were both analyzed as continuous variables, and the results suggested that cystatin C other than eGFR was associated with hemodialysis initiation.…”

“…First, it reflects the patterns of a single center in China, and the findings may not generalize to some dialysis centers. It is reassuring that the proportion of patients with predialysis AVF surgery initiating hemodialysis within 1 year (91.7%) was remarkably similar to that (89.3%) reported in a Japanese multicenter cohort study [9]. Second, some factors that may affect the timing of predialysis vascular access, such as preoperative vascular mapping, surgeon experience, or patient preferences, were not available in the datasets and were therefore not incorporated into the statistical models.…”

Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment

“…Although whether the reported survival benefits of arteriovenous access preparation are caused directly by reduced catheter-related infections should be investigated in further studies, a recent study reported that mortality after sepsis was higher in the AVG group than the AVF group [21]. A potential harm of preparing an arteriovenous access is unnecessary creation, defined as an AVF failure or patient death during the predialysis period, and that risk is elevated in elderly patients and female patients [22].…”