Timing of Arteriovenous Fistula Creation in Patients With CKD: A Decision Analysis

Shechter, Steven M.; Skandari, M. Reza; Zalunardo, Nadia

doi:10.1053/j.ajkd.2013.06.021

Cited by 56 publications

(50 citation statements)

References 37 publications

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“…A simulation study also demonstrated that aging increased the risk of unnecessary AVF creation, mainly due to the competing risk of death [14]. Although the low BMI in our study (mean 23.4) relative to that in a US study (median BMI 30) [9] might have been attributed to the low incidence of unnecessary AVF creation and primary thrombosis, BMI was not associated with unnecessary AVF creation, probably due to the paucity of patients with obesity.…”

Section: Discussionmentioning

confidence: 99%

“…The primary outcome was “unnecessary AVF creation,” defined as AVF failure or death, whichever came first, during the predialysis period [14]. AVF failure was defined as: (1) requirement of vascular access intervention therapy (VAIVT) for non-mature or AVF thrombosis; (2) requirement of surgical correction for non-mature, AVF thrombosis, venous hypertension, or steal syndrome; or (3) non-mature or AVF thrombosis without any further intervention, before dialysis commencement.…”

Section: Methodsmentioning

confidence: 99%

“…A US study found that among primarily stages 3 and 4 CKD patients (overall, 78%), the AVF failure and mortality rates during the predialysis periods were 63 and 23%, respectively [9]. Some experts have, therefore, considered postponing the timing of AVF creation, a notion supported by the findings of several simulation studies [14,15]. However, few studies have described the outcomes of AVF among patients who receive AVF in the late CKD stages in actual clinical practice settings.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2017

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2017

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“…Selection of the optimal eGFR for access surgery requires finding the optimal balance between placing the access too early and placing the access too late. A recent computer simulation evaluated the likelihood of starting hemodialysis when AVFs were created in patients at different eGFR values (18). According to that model, the likelihood rates of starting hemodialysis after AVF creation were 80% and 90% when eGFRs at the time of surgery were ,20 and 15 ml/min per 1.73 m 2 , respectively.…”

Section: Discussionmentioning

confidence: 99%

Predictors of Initiation for Predialysis Arteriovenous Fistula

Al-Balas¹,

Lee

Young

et al. 2016

CJASN

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Background and objectives The optimal timing of predialysis arteriovenous fistula surgery remains uncertain. We evaluated factors associated with hemodialysis initiation in patients undergoing predialysis arteriovenous fistula surgery and derived a model to predict future initiation of dialysis.Design, setting, participants, & measurements Our study retrospectively identified 308 patients undergoing predialysis arteriovenous fistula creation at a large medical center in 2006-2012 to determine whether they initiated hemodialysis. Multiple variable logistic regression analyzed which demographic and clinical factors predicted initiation of dialysis within 2 years of arteriovenous fistula surgery. A receiver operating characteristic area under the curve was used to quantify the predictive value of preoperative factors on the likelihood of initiating hemodialysis within 2 years.Results Overall, hemodialysis was initiated within 6 months, 1 year, and 2 years in 119 (39%), 175 (57%), and 211 (68%) patients, respectively. Using multiple variable logistic regression, four factors were associated with hemodialysis initiation at 2 years: eGFR at access surgery (odds ratio, 0.45; 95% confidence interval, 0.31 to 0.64 per 5 ml/min per 1.73 m 2 ; P,0.001), diabetes (odds ratio, 2.51; 95% confidence interval, 1.22 to 5.15; P=0.003), GFR trajectory (odds ratio, 1.54; 95% confidence interval, 1.09 to 2.17 per 3 ml/min per 1.73 m 2 per year; P=0.01), and spot urine protein-to-creatinine ratio (odds ratio, 1.39; 95% confidence interval, 1.14 to 1.71 per 1 U; P,0.001). eGFR alone had a moderate predictive value for dialysis initiation (area under the curve =0.69; 95% confidence interval, 0.63 to 0.76; P,0.001), whereas the full model had a higher predictive value (area under the curve =0.83; 95% confidence interval, 0.77 to 0.88; P,0.001).Conclusions The likelihood of initiating hemodialysis within 2 years of predialysis arteriovenous fistula surgery is associated with eGFR at access surgery, diabetes, GFR trajectory, and magnitude of proteinuria. The combined use of all four variables improves the ability to predict future hemodialysis compared with the use of eGFR alone.

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“…Lok et al [10] developed a scoring system to estimate the risk of failure of AVF maturation in incident dialysis patients but, as seen in our study, the reasons for non-use of AVF are not just limited to failure of AV access to mature. Shechter et al [22] recently published a decision modelling study to address the problem of trying to minimize the likelihoods of both the need for central venous catheter and the creation of unnecessary AVFs and concluded that the timing of referral should be guided by the individual rate of CKD progression and elderly patients with CKD could be referred later to reduce the risk of creating an AVF that is never used.…”

Section: Discussionmentioning

confidence: 99%

Predictors of Sustained Arteriovenous Access Use for Haemodialysis

Stoumpos¹,

Stevens²,

Aitken³

et al. 2014

Am J Nephrol

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Background: Guidelines encourage early arteriovenous (AV) fistula (AVF) planning for haemodialysis (HD). The aim of this study was to estimate the likelihood of sustained AV access use taking into account age, sex, comorbidity, anatomical site of first AVF and, for pre-dialysis patients, eGFR and proteinuria. Methods: 1,092 patients attending our centre who had AVF as their first AV access procedure between January 1, 2000 and August 23, 2012 were identified from the electronic patient record. The primary end-point was time to first sustained AV access use, defined as use of any AV access for a minimum of 30 consecutive HD sessions. Results: 52.9% (n = 578) of the patients ultimately achieved sustained AV access use. The main reasons for AV access non-use were AVF failure to mature and death. The 3-year Kaplan-Meier probability of sustained AV access use was 68.8% for those not on renal replacement therapy (RRT) (n = 688) and 74.2% for those already on RRT (n = 404) at the time of first AVF. By multivariate analysis in patients not on RRT, male sex (HR 2.22; p < 0.001), uPCR (HR 1.03; p = 0.03) and eGFR (hazard ratio, HR 0.85; p < 0.001) were independent predictors of AV access use. In patients already on RRT, age (HR 0.98; p < 0.001) and peripheral vascular disease (HR 0.48; p = 0.02) were independent predictors of AV access use. Conclusion: Our data suggest that refinement of the current guideline for timing of AV access creation in planning RRT is justified to take into account individual factors that contribute to the likelihood of technical success and clinical need.

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Timing of Arteriovenous Fistula Creation in Patients With CKD: A Decision Analysis

Cited by 56 publications

References 37 publications

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

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

Predictors of Initiation for Predialysis Arteriovenous Fistula

Predictors of Sustained Arteriovenous Access Use for Haemodialysis

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