The outcome of the primary vascular access and its translation into prevalent access use rates in chronic haemodialysis patients

Abstract

BackgroundThe American Fistula First Breakthrough Initiative currently aims for a 66% arterio-venous fistula (AVF) rate, while in the UK, best practice tariffs target AVF and arterio-venous graft (AVG) rates of 85%. The present study aims to assess whether these goals can be achieved.MethodsWe conducted a retrospective cohort study on patients who initiated haemodialysis from 1995 to 2006. Outcomes were the final failure-free survival of the first permanent access and the type of second access created. Prevalent use rates for the access types were calculated on the 1st January of each year for the second half of the study period.ResultsTwo hundred and eleven out of 246 patients (86%) received an AVF, 16 (6%) an AVG and 19 (8%) a permanent catheter (PC) as the first permanent access. Eighty-six (35%) patients had final failure of the primary access. One- and 3-year final failure-free survival rates were 73 and 65% for AVF compared with 40 and 20% for AVG and 62 and 0% for PC, respectively. In patients with primary AVF, female sex {hazard ratio (HR) 2.20 [confidence interval (CI) 1.29–3.73]} and vascular disease [HR 2.24 (CI 1.26–3.97)] were associated with a poorer outcome. A similar trend was observed for autoimmune disease [HR 2.14 (CI 0.99–4.65)]. As second accesses AVF, AVG and PC were created in 47% (n = 40), 38% (n = 33) and 15% (n = 13). The median prevalent use rate was 80.5% for AVF, 14% for AVG and 5.5% for PC.ConclusionsThe vascular access targets set by initiatives from the USA and UK are feasible in unselected haemodialysis patients. High primary AVF rates, the superior survival rates of AVFs even in patient groups at higher risk of access failure and the high rate of creation of secondary AVFs contributed to these promising results.

Arteriovenous Fistula Nonmaturation: What’s the Immune System Got to Do with It?

“…It has been suggested that worse AVF maturation outcomes in females may be due to smaller baseline blood vessel diameters relative to males (9). Yet a number of subsequent studies have reported that females have inferior rates of AVF maturation than males, despite similar preoperative vascular diameters, consistent with this study’s findings (7,12 –14). Of note, on multivariable analysis, female sex was no longer an independent predictor of AVF nonmaturation, whereas Black race persisted.…”

“…A study using the Hemodialysis Fistula Maturation (HFM) cohort reported that early AVF thrombosis was three times higher in females vs males, and twice as high in Black vs white patients, although this racial difference was not statistically significant (11). Sex and racial disparities in AVF maturation outcomes are not adequately explained by differences in clinical characteristics or pre-operative blood vessel diameters, suggesting that additional unidentified factors contribute to AVF non-maturation, especially in the populations at risk for poor AVF maturation outcomes (7,(12)(13)(14).…”

Assessment of Use of Arteriovenous Graft vs Arteriovenous Fistula for First-time Permanent Hemodialysis Access

“…These data suggest that high AVG use is an area of low-value care that can be addressed at the surgeon level. Most previously published literature reporting trends of hemodialysis access focus on the type of access used at the time of incident hemodialysis 3,12 or rates of prevalent dialysis access type. 7, 11,16 Lynch et al 7 reported that the percentage of US facilities achieving the 66% AVF goal increased from 6.4% in 2007 to 19.0% in 2010.…”

“…The type of hemodialysis access chosen for a patient has a direct effect on complication rates and health care costs. Typically, complications and mortality are significantly lower with arteriovenous fistula (AVF) compared with arteriovenous graft (AVG) or central venous catheter use . In addition, the cost associated with an AVF ($60 000 per person per year) is markedly lower than the cost of an AVG ($72 729 per person per year) .…”

“…Typically, complications and mortality are significantly lower with arteriovenous fistula (AVF) compared with arteriovenous graft (AVG) or central venous catheter use. [2][3][4][5][6] In addition, the cost associated with an AVF ($60 000 per person per year) is markedly lower than the cost of an AVG ($72 729 per person per year). 7 As a result, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative clinical practice guidelines for hemodialysis access recommend the use of AVF whenever feasible.…”