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Predialysis Vascular Access Placement and Catheter Use at Hemodialysis Initiation
Michael Allon1, Alian Al-Balas1, Carlton J Young2
1Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama.
Insights
For advanced chronic kidney disease (CKD) patients needing dialysis, arteriovenous grafts (AV grafts) are more effective than arteriovenous fistulas (AV fistulas) at preventing central venous catheter use. AV grafts lead to catheter-free dialysis initiation in most CKD patients.
Area of Science:
- Nephrology
- Vascular Surgery
- Dialysis Access
Background:
- Current guidelines recommend arteriovenous (AV) fistula placement for advanced chronic kidney disease (CKD) patients to avoid central venous catheter (CVC) use for hemodialysis.
- Limited research exists on the comparative effectiveness of predialysis AV fistula versus AV graft placement.
- Vascular access is critical for hemodialysis, with CVCs associated with higher morbidity and mortality compared to AV fistulas or grafts.
Purpose of the Study:
- To compare the outcomes of predialysis AV fistula versus AV graft placement in patients with advanced CKD.
- To evaluate the time to dialysis initiation, likelihood of catheter-free initiation, and number of access procedures.
- To inform clinical decision-making regarding the optimal type of vascular access for CKD patients approaching end-stage renal disease.
Main Methods:
- Retrospective study of 380 CKD patients undergoing predialysis AV fistula (n=286) or AV graft (n=94) placement at a large academic medical center.
- Data collected included patient demographics, estimated glomerular filtration rate (eGFR) at surgery, time from access placement to dialysis initiation, and need for CVC.
- Outcomes analyzed: time to hemodialysis initiation, catheter-free hemodialysis initiation rate, and number of vascular access procedures prior to dialysis.
Main Results:
- Median time to hemodialysis initiation varied significantly by eGFR: 69 days (<10 ml/min/1.73 m²), 156 days (10-14 ml/min/1.73 m²), and 429 days (≥15 ml/min/1.73 m²).
- Catheter-free hemodialysis initiation was significantly higher with AV grafts compared to AV fistulas when eGFR was <10 ml/min/1.73 m² (88% vs. 43%) and 10-14 ml/min/1.73 m² (88% vs. 54%).
- Patients receiving AV fistulas were more likely to require angioplasty, surgical revision, a second access placement, and CVC insertion compared to those receiving AV grafts.
Conclusions:
- In CKD patients with eGFR <15 ml/min/1.73 m² undergoing vascular access surgery, AV grafts significantly reduce the likelihood of needing a CVC at dialysis initiation compared to AV fistulas.
- AV grafts appear to be a superior option for timely and catheter-free dialysis access in many predialysis CKD patients.
- Further prospective studies are warranted to confirm these findings and optimize predialysis vascular access strategies.
Background:
Current guidelines encourage placement of an arteriovenous (AV) fistula in patients with advanced CKD to avoid initiation of hemodialysis with a central venous catheter. However, the relative merits of predialysis placement of an AV fistula or graft have been poorly studied.
Methods:
This study included 380 patients (mean age 59±14 years, 73% Black patients, 51% male) from a large academic medical center who underwent predialysis placement of an AV fistula (286) or AV graft (94). The study quantified three end points: time from access placement to initiation of dialysis, likelihood of starting hemodialysis without a catheter, and number of vascular access procedures before dialysis initiation.
Results:
The eGFR at access surgery was <10, 10-14, and ≥15 ml/min per 1.73 m 2 in 87 (23%), 179 (47%), and 114 (30%) patients, respectively. The median time from access surgery to hemodialysis initiation was 69, 156, and 429 days in patients with an eGFR of <10, 10-14, and ≥15 ml/min per 1.73 m 2 , respectively ( P < 0.001). Hemodialysis was initiated within 2 years of access surgery in 298 (78%) of the patients. Catheter-free hemodialysis initiation was higher in patients with an AV graft versus an AV fistula when the eGFR was <10 ml/min per 1.73 m 2 (88% versus 43%; odds ratio [OR], 9.10 [95% confidence interval, 2.74 to 26.4]) and when the eGFR was 10-14 ml/min per 1.73 m 2 (88% versus 54%; OR, 6.05 [2.35 to 15.0]) but similar when the eGFR was ≥15 ml/min per 1.73 m 2 (90% versus 75%; OR, 3.00 [0.48 to 34.9]). Patients undergoing an AV fistula were more likely to undergo an angioplasty (11% versus 0%, P < 0.001), surgical access revision (26% versus 8%, P < 0.001), a second access placement (16% versus 6%, P = 0.02), and a catheter insertion (32% versus 11%, P < 0.001).
Conclusions:
Among patients with CKD undergoing vascular access surgery when their eGFR was <15 ml/min per 1.73 m 2 , catheter use at dialysis initiation was much less likely when an AV graft, rather than an AV fistula, was placed.
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