Outcomes of Simultaneous Peritoneal Dialysis and Arteriovenous Fistula Placement in End-Stage Renal Disease Patients

Abstract

Peritoneal dialysis (PD) interruption requiring hemodialysis (HD) is not uncommon and its frequently abrupt nature prevents timely creation of permanent HD access and avoidance of central venous catheters (CVC). We retrospectively studied a cohort of 24 end-stage renal disease (ESRD) patients (mean age 50.7 years, 83.3% African-Americans, 58.3% females, time on dialysis interquartile range [IQR] 0 - 65 days) who had simultaneous PD catheter insertion and backup arteriovenous fistula (AVF) creation between January 1, 2012, and December 31, 2013. The primary outcome of interest was the percent of patients receiving HD through the backup AVF at the time of PD interruption. A median (IQR) for PD catheter use after its insertion was 10.5 (2 - 20) days. After the mean follow-up of 19.6 months, 12 patients remained on PD, 2 patients received a kidney transplant, and 1 patient died. The overall AVF patency was 66.7%. A total of 9 (37.5%) patients had PD interruption requiring permanent (8 patients) or temporary (1 patient) HD after the mean (standard deviation [SD]) follow-up of 12.3 (8.2) months. Arteriovenous fistula was used as the initial access in 4 patients, and in 3 patients the original AVF was used after additional surgical revision. Forty-four percent of patients with a backup AVF fistula avoided CVC at the time of PD interruption requiring HD. The simultaneous AVF creation at the time of PD catheter insertion reduced but did not fully eliminate CVC at the time of PD interruption. Larger studies are needed to evaluate the utility of a backup AVF in PD patients.

Optimization of Dialysis Modality Transitions for Improved Patient Care

“…A small report of 24 patients in whom an AVF was created at time of PD catheter insertion found that only 3 patients (12.5%) were started on CHD using the AVF. 70 This is similar to older data from the United Kingdom where 9% of PD patients with an AVF used this access to start CHD. 71 Overall, identifying the optimal time for access creation and transition to CHD where time on PD is maximized while complications and crash-transitions are minimized remains key and should be explored in future research.…”

Do arteriovenous fistulas increase cardiac risk?

“…Our unit policy is to have a back‐up fistula in peritoneal dialysis patients under certain circumstances—the patient is likely to require peritoneal dialysis for an extended period (eg, does not have an impending live donor kidney transplant arranged); the patient has suitable vessels to construct a straightforward fistula; and the patient consents to the additional operative procedure. In practice at least 50% of our patients on peritoneal dialysis have a functioning fistula as well …”

“…In practice at least 50% of our patients on peritoneal dialysis have a functioning fistula as well. 3 The other patient group where a functioning fistula lies unused is those who have had a successful kidney transplant. While these fistulas may spontaneously thrombose in some cases, they may also increase in size and remain unused.…”

Characteristics Associated With Peritoneal Dialysis Technique Failure: Are We Asking the Right Questions?

“…Generally, creation of a permanent vascular access at the start of PD as a "back-up" plan is not advised because only a small (w10%) proportion of patients end up using their AVF, either due to a competing event (transplantation or death) or nonfunctioning AVF when HD is required. 9 Clinicians are often faced with the challenge of identifying patients who will be successful on PD therapy. The study by McGill et al has aimed to improve the level of evidence in this area.…”