Arteriovenous Fistula Maturation Failure in a Large Cohort of Hemodialysis Patients in the Netherlands

World Journal of Surgery, Nov 2017

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.

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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)


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Bram M. Voorzaat, Koen E. A. van der Bogt, Cynthia J. Janmaat, Jan van Schaik, Friedo W. Dekker, Joris I. Rotmans, on behalf of the Dutch Vascular Access Study Group. Arteriovenous Fistula Maturation Failure in a Large Cohort of Hemodialysis Patients in the Netherlands, World Journal of Surgery, 2017, pp. 1-9, DOI: 10.1007/s00268-017-4382-z