Who should be referred for a fistula? A survey of nephrologists

Xi, Wang; Macnab, Jennifer; Lok, Charmaine E.; Lee, Timmy C.; Maya, Ivan D.; Mokrzycki, Michele H.; Moist, Louise

doi:10.1093/ndt/gfq064

Cited by 55 publications

(59 citation statements)

References 33 publications

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“…However, increasing rates of catheter use are documented in Canadian and Australian patientsand in both Canada and the United States approximately 80% of patients still initiate hemodialysis with a catheter (24)(25)(26). In addition, for patients with failed fistulas, Canadian nephrologists are more likely to consider a catheter rather than a graft, but the reverse is true for nephrologists in the United States (38). This is concerning because catheter use is associated with an increased risk for infectionrelated hospitalizations, frequent catheter malfunction due to thrombosis, inflammation, and mortality (27,(39)(40)(41)(42).…”

Section: Discussionmentioning

confidence: 99%

Cumulative Patency of Contemporary Fistulas versus Grafts (2000–2010)

Lok

Sontrop

Tomlinson

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Comparisons of fistulas and grafts often overlook the high primary failure rate of fistulas. This study compared cumulative patency (time from access creation to permanent failure) of fistulas and grafts.Design, setting, participants, & measurements Vascular accesses of 1140 hemodialysis patients from two centers (Toronto and London, Ontario, Canada, 200022010) were analyzed. Cumulative patency was compared between groups using Kaplan-Meier survival curves and log-rank tests. Hazard ratios (HRs) for fistula failure relative to grafts and 95% confidence intervals (95% CIs) are reported.Results There were 1012 (88.8%) fistulas and 128 (11.2%) grafts. The primary failure rate was two times greater for fistulas than for grafts: 40% versus 19% (P,0.001). Cumulative patency did not differ between fistulas and grafts for the patients' first access (median, 7.4 versus 15.0 months, respectively [HR, 0.99; 95% CI, 0.7921.23; P=0.85]) or for 600 with a subsequent access (7.0 versus 9.0 months [HR, 0.93; 95% CI, 0.7721.13; P=0.39]). However, when primary failures were excluded, cumulative patency became significantly longer for fistulas than for grafts for both first and subsequent accesses (61.9 versus 23.8 months [HR, 0.56; 95% CI, 0.4320.74; P,0.001] and 42.8 versus 15.9 months [HR, 0.56; 95% CI, 0.4420.72; P,0.001]). Results were similar for forearm and upper-arm accesses. Compared with functioning fistulas, grafts necessitated twice as many angioplasties (1.4 versus 3.2/ 1000 days, respectively; P,0.001) and significantly more thrombolysis interventions (0.06 versus 0.98/1000 days; P,0.001) to maintain patency once matured and successfully used for dialysis.Conclusions Cumulative patency did not differ between fistulas and grafts; however, grafts necessitated more interventions to maintain functional patency.

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Section: Discussionmentioning

confidence: 99%

Cumulative Patency of Contemporary Fistulas versus Grafts (2000–2010)

Lok

Sontrop

Tomlinson

et al. 2013

Clinical Journal of the American Society of Nephrology

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206

201

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“…In addition, Canadians face challenging system-wide barriers to AV access creation, such as limited access to surgical services (6,24,25). Furthermore, because of the lack of validated standardized eligibility criteria for AV access creation, there exists large variation in vascular access use across hemodialysis programs (8,22,26). Vascular access use is not driven solely by patient characteristics, and the effects of center-specific variables influence patterns of use (27).…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, Canadian patients and health care providers have attitudes that are markedly different from the rest of the world, and it would seem that Canada has a culture that is more permissive of catheters (22). In surveys, we have found that this attitude is pervasive among patients, and nephrologists as well as vascular access surgeons had marked variations in their practices regarding AV access referral patterns and creation, respectively (26,28,29). (1-3).…”

Section: Discussionmentioning

confidence: 99%

Vascular Access Creation before Hemodialysis Initiation and Use

Al-Jaishi

Lok

Garg

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives In Canada, approximately 17% of patients use an arteriovenous access (fistula or arteriovenous graft) at commencement of hemodialysis, despite guideline recommendations promoting its timely creation and use. It is unclear if this low pattern of use is attributable to the lack of surgical creation or a high nonuse rate.Design, setting, participants, & measurements Using large health care databases in Ontario, Canada, a population-based cohort of adult patients ($18 years old) who initiated hemodialysis as their first form of RRT between 2001 and 2010 was studied. The aims were to (1) estimate the proportion of patients who had an arteriovenous access created before starting hemodialysis and the proportion who successfully used it at hemodialysis start, (2) test for secular trends in arteriovenous access creation, and (3) estimate the effect of late nephrology referral and patient characteristics on arteriovenous access creation.Results There were 17,183 patients on incident hemodialysis. The mean age was 65.8 years, 60% were men, and 40% were referred late to a nephrologist; 27% of patients (4556 of 17,183) had one or more arteriovenous accesses created, and the median time between arteriovenous access creation and hemodialysis start was 184 days. When late referrals were excluded, 39% of patients (4007 of 10,291) had one or more arteriovenous accesses created, and 27% of patients (2724 of 10,291) used the arteriovenous access. Since 2001, there has been a decline in arteriovenous access creation before hemodialysis initiation. Women, higher numbers of comorbidities, and rural residence were consistently associated with lower rates of arteriovenous access creation. These results persisted even after removing patients with ,6 months nephrology care or who had AKI 6 months before starting hemodialysis.Conclusions In Canada, arteriovenous access creation before hemodialysis initiation is low, even among patients followed by a nephrologist. Better understanding of the barriers and influencers of arteriovenous access creation is needed to inform both clinical care and guidelines.

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“…We also analyzed subgroups divided by sex, race, and specific comorbidities (i.e., diabetes and CHF) to evaluate the potential effect of the characteristic on the vascular access outcome. 3,40 The logistical regression model was adjusted for the following covariates: age at HD initiation, race, sex, comorbidities, primary cause of ESRD, BMI, duration of nephrology care, geographic location, substance abuse (history of smoking, alcohol, or street drugs), employment index, race-stratified annual median income, and testing of the interaction term between the number of procedures and time.…”

Section: Statistical Analysesmentioning

confidence: 99%

Arteriovenous Fistula Placement in the Elderly

Hod

Patibandla

Vin

et al. 2015

Journal of the American Society of Nephrology

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Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). However, many AVFs fail before starting dialysis. To assess the optimal time for AVF placement in the elderly, we linked data from the US Renal Data System with Medicare claims data to identify 17,511 patients$67 years old on incident HD who started dialysis between January 1, 2005, and December 31, 2008, with an AVF placed as the first predialysis access. AVF success was defined as dialysis initiation using the AVF, with time between AVF placement and dialysis start as our primary variable of interest. The mean age was 76.166.0 years, and 58.3% of subjects were men. Overall, 54.9% of subjects initiated dialysis using an AVF, and 45.1% of subjects used a catheter or graft. The success rate increased as time from AVF creation to HD initiation increased from 1-3 months (odds ratio [OR], 0.49; 95% confidence interval [95% CI], 0.44 to 0.53) to 3-6 months (OR, 0.93; 95% CI, 0.85 to 1.02) to 6-9 months (OR, 0.99; 95% CI, 0.88 to 1.11) but stabilized after that time. Furthermore, the number of interventional access procedures increased over time starting at 1-3 months, with a mean of 0.64 procedures/patient for AVFs created 6-9 months predialysis compared with 0.72 for AVFs created .12 months predialysis (P,0.001). Although limited by the observational nature of this study, our results suggest that placing an AVF.6-9 months predialysis in the elderly may not associate with a better AVF success rate.

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Who should be referred for a fistula? A survey of nephrologists

Abstract: This study demonstrated marked variability in timing and criteria used to select patients for referral for a vascular access between nephrologists practicing within Canada and the USA. Establishing minimal eligibility criteria for fistulae is an important area of future research.

Cited by 55 publications

References 33 publications

Cumulative Patency of Contemporary Fistulas versus Grafts (2000–2010)

Cumulative Patency of Contemporary Fistulas versus Grafts (2000–2010)

Vascular Access Creation before Hemodialysis Initiation and Use

Arteriovenous Fistula Placement in the Elderly

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