Slowly moving the needle away from Fistula First

Area of Science:

• Nephrology
• Vascular Surgery
• Public Health

Background:

• The
• Fistula First
• policy prioritized arteriovenous fistula (AVF) creation for end-stage kidney disease (ESKD) patients.
• This approach may not suit all patients, particularly those with significant comorbidities.
• A shift towards
• ESKD Life-Plan: Patient Life-Plan First then Access Needs
• was proposed in 2019.

Purpose of the Study:

• To retrospectively evaluate complications and mortality associated with AVF creation under the
• Fistula First
• policy.
• To determine the rate of operative futility in AVF procedures.

Main Methods:

• Retrospective review of 401 consecutive AVFs created before 2021.
• Analysis of operative futility, defined by criteria including failure to mature, lack of dialysis initiation, access-related complications, or early mortality.
• Statistical analysis to identify predictors of complications and futility.

Main Results:

• 52% of AVF operations were deemed futile, with 40% failing to mature and 13% never used for dialysis.
• Patients over 80 years old had significantly higher rates of cardiac events (19% vs. 8%) and major morbidity (OR, 2.01).
• Prior catheter-based dialysis was protective against operative futility (OR, 0.36).

Conclusions:

• The
• Fistula First
• era saw substantial operative futility (52%) in AVF creation for ESKD.
• Octogenarians were particularly vulnerable to complications and futility.
• The shift to an
• ESKD Life-Plan
• approach is crucial for tailoring vascular access to individual patient needs.