Predictors of Arteriovenous Fistula Failure: A Post Hoc Analysis of the FAVOURED Study

Abstract

Background An autologous arteriovenous fistula (AVF) is the preferred hemodialysis vascular access but successful creation is hampered by high rates of AVF failure. This study aimed to evaluate patient and surgical factors associated with AVF failure to improve vascular access selection and outcomes. Methods This is a post-hoc analysis of all participants of FAVOURED, a multi-center, double-blind, multinational, randomized placebo-controlled trial evaluating the effect of fish oil and/or aspirin in preventing AVF failure in patients receiving hemodialysis. The primary outcome of AVF failure was a composite of fistula thrombosis and/or abandonment and/or cannulation failure at 12 months post AVF creation and secondary outcomes included individual outcome components. Patient data (demographics, comorbidities, medications and laboratory data) and surgical factors (surgical expertise, anesthetic, intraoperative heparin use) were examined using multivariable logistic regression analyzes to evaluate associations with AVF failure. Results Of 536 participants, 253 patients (47%) experienced AVF failure during the study period. The mean age was 55 ± 14.4 years, 64% were male, 45% were diabetic and 4% had peripheral vascular disease. Factors associated with AVF failure included female sex (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.20-2.68), lower diastolic blood pressure (OR for higher DBP 0.85, 95% CI 0.74-0.99), presence of central venous catheter (OR 1.49, 95% CI 1.02-2.20, p=0.04) and aspirin requirement (OR 1.60, 95% CI 1.00-2.56). Conclusions 3 Female sex, requirement for aspirin therapy, requiring hemodialysis via a central venous catheter and lower diastolic blood pressure were factors associated with higher odds of AVF failure. These associations have potential implications for vascular access planning and warrant further studies.

Reproducibility in Research: The Role of Kidney360

“…Immune checkpoint inhibitors may cause acute interstitial nephritis 13 Remote monitoring of patients on peritoneal dialysis reduces hospitalizations and technique failure 14 Arteriovenous failure to mature increases access-related costs in hemodialysis patients 15 Scintigraphy is a simple and reliable tool to diagnose PD fluid leaks 16 Hypoglycemia is common in patients with diabetes and chronic kidney disease 17 Functional patency was similar for arteriovenous fistulas and grafts, but the latter required more frequent interventions to maintain access patency 18 Hemodialysis patient mortality is increased in patients with PTH levels .450 or ,350 pg/ml 19 Nondiabetic kidney disease is identified frequently in diabetic patients undergoing a kidney biopsy 20 Arteriovenous failure is more common in hemodialysis patients who are female, have a lower diastolic blood pressure, or who have a central vein catheter 21 Tonsillectomy is associated with slower progression of kidney disease in patients with IgA nephropathy 22 Patients with COVID-19 requiring ICU admission had a high rate of AKI and mortality 23 In patients hospitalized with COVID-19 and severe AKI requiring CRRT, there is a high frequency of loss of patency of the dialysis circuit due to thrombosis 24 In patients with advanced CKD, the rate of decline of kidney function is slower after creation of an arteriovenous fistula 25 An unhealthy diet is associated with a faster decline of kidney function 26 A faster decline in kidney function is associated with higher mortality and cardiovascular events 27 In patients with focal glomerular sclerosis, a higher risk of end-stage kidney disease is associated with nephrotic range proteinuria, hypoalbuminemia, interstitial fibrosis and tubular atrophy, and absence of remission 28 Acute tubular necrosis is a common kidney biopsy finding in patients with COVID-19 and acute kidney injury 29 The use of an arteriovenous fistula or graft at initiation of hemodialysis varies greatly among dialysis centers 30 A high proportion of patients initiate hemodialysis with a central vein catheter, and a sizable proportion is still catheter-dependent after 1 year 31 The "surprise question" is highly predictive of 1-year mortality in patients with advanced chronic kidney disease 32 Post-transplant diabetes is common and associated with older age and obesity 33 Bleeding complications after a kidney biopsy are more common in female patients 34 The immune response to the COVID-19 vaccine is impaired in dialysis and kidney transplant patients…”

Gender and Renal Insufficiency: Opportunities for Their Therapeutic Management?

“…This male predominance is explained by the greater progression of renal biological damage attributed to it but also by a greater awareness of the disease from the earliest stages of onset. Women, on the other hand, especially those in their senior years, preferentially choose to practice conservative treatments, trying to procrastinate the most invasive treatments as much as possible [ 91 , 92 , 93 ]. This attitude is largely explained by the fact that more and more women live alone, live longer than men, and more easily refuse the help of a caregiver.…”

Shared decision-making in hemodialysis vascular access practice

“…Continued research is essential to identify factors that predict AV access outcomes and compile the results into reliable risk prediction tools. [81][82][83][84][85] Finally, vascular access decision aids need to be developed and incorporate information, derived from high-quality data, about benefits, risks, and uncertainties associated with each vascular access option. 86 We envision that creation of >1 category of decision aids is necessary to address varied nuances of vascular access care (e.g., vascular access decision-making before or after dialysis initiation, in patients with or without prior AV access, or in patient with poor or good prognosis).…”