Arteriovenous Fistula Maturation Failure in a Large Cohort of Hemodialysis Patients in the Netherlands
Arteriovenous Fistula Maturation Failure in a Large Cohort of Hemodialysis Patients in the Netherlands
Bram M. Voorzaat 0 1 2 3
Koen E. A. van der Bogt 0 1 2 3
Cynthia J. Janmaat 0 1 2 3
Jan van Schaik 0 1 2 3
Friedo W. Dekker 0 1 2 3
Joris I. Rotmans 0 1 2 3
0 Department of Surgery, Haaglanden Medical Center , The Hague , The Netherlands
1 Department of Surgery, Leiden University Medical Center , Leiden , The Netherlands
2 & Bram M. Voorzaat
3 Department of Clinical Epidemiology, Leiden University Medical Center , Leiden , The Netherlands
Objectives Radiocephalic arteriovenous fistulas (RCAVF) are the preferred vascular access (VA) for hemodialysis (HD). Cohort studies from North America revealed that nonmaturation is a significant disadvantage of RCAVFs compared to other VAs. DESIGN: This present retrospective study describes the incidence of nonmaturation of AVFs and functional failure of arteriovenous grafts (AVG) in a multicentre cohort in the Netherlands and attempts to create a prediction model for nonmaturation of RCAVFs. Furthermore, the efficacy of interventions to promote maturation as well as the variability between hemodialysis centers was evaluated. Materials Medical records from 8 hospitals from 1997 to 2016 were retrospectively evaluated for VA type, maturation/ primary success and demographics and comorbidities. Methods A prediction model was created for RCAVF nonmaturation using multivariate logistic regression analysis, selecting significant predictors using backward selection. Discrimination and calibration of the model were assessed. Results 1383 AVFs and 273 AVGs were included in 1221 patients. Overall nonmaturation was 24% for RCAVFs, and 11% for upper arm AVFs. The functional failure rate for AVGs was 6%. The nonmaturation rate of contralateral RCAVFs after failure of an RCAVF was 22%. Procedures to improve RCAVF maturation were successful in 98/142 cases (69%). Predictors for nonmaturation were female gender, peripheral vascular disease, cerebrovascular disease and a cephalic vein diameter 2.5 mm, but the prediction model lacked sensitivity and specificity predicting individual RCAVF nonmaturation (C-statistic 0.629). Conclusion Nonmaturation rates are highest for RCAVFs, but nonmaturation could not be predicted with demographic parameters.
Introduction
Department of Internal Medicine, Leiden University Medical
Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
The arteriovenous fistula (AVF) is the preferred type of
permanent vascular access (VA) in maintenance
hemodialysis (HD) patients. AVFs are associated with a
lower incidence of patency-related procedures than
arteriovenous grafts (AVGs) and less infectious complications
than both AVGs and central venous catheters (CVC). As a
consequence, healthcare costs are lowest for patients with
an AVF, compared to patients with an AVG or CVC [
1
].
Both the NKF KDOQI and EBPG guidelines advocate
the creation of AVFs distally in the upper extremity
whenever possible [
1, 2
]. Radiocephalic AVFs (RCAVFs)
have the advantage of preservation of more proximal
options for future VAs in case of access failure. In addition,
RCAVFs are associated with a lower incidence of HD
access-induced distal ischemia [3], when compared to
upper arm AVFs. High flow also predisposes to increased
cardiac output and impaired systemic blood flow in patients
with impaired cardiac function, a phenomenon known as
‘AVF cardiotoxicity’ [
4, 5
].
The main disadvantage of RCAVFs is nonmaturation,
characterized by inadequate dimensions of the venous
outflow tract or insufficient blood flow [
6
]. Although a
uniform definition of nonmaturation is lacking, rates up to
65% are reported [
7
]. Forearm location and female gender
are well-known risk factors for early failure [
8
]. A decade
ago, Lok and co-workers [
9
] developed a scoring system to
predict nonmaturation in a North American cohort.
Predictors were age over 65 years, female gender, non-white
race, and coronary and peripheral arterial disease.
Most studies on AVF maturation are from the USA and
Canada. As demonstrated in the DOPPS study, CVC
preference is higher [
10
] and AVF cannulation is
performed later [
11
] than in Europe. Other significant
differences are ethnicity, BMI and cardiovascular comorbidities
[
12
]. The aim of the current study was to evaluate the
incidence of nonmaturation of RCAVFs and upper arm
AVFs in a large cohort in the Netherlands and to create a
prediction model for RCAVF nonmaturation. As a
comparator group, functional failure of AVGs was also
assessed. In addition, the efficacy of interventions to promote
maturation as well as the variability between HD centers
was assessed.
Methods
Patient selection
Adult patients who underwent creation of an AVF or AVG
as a permanent VA for maintenance HD were
retrospectively identified in 5 affiliated teaching hospitals and 3
academic hospitals in the Netherlands. To prevent
survivorship bias, the time frame var (...truncated)