Predialysis vascular access placement
Abstract:
Background: Current guidelines encourage placement of an arteriovenous (AV) fistula in patients with advanced chronic kidney disease to avoid initiation of hemodialysis with a central venous catheter. However, the relative merits of pre-dialysis placement of an AV fistula or graft has been poorly studied.
Methods: The current study included 380 patients (mean age 59 ± 14 years, 73% Black patients, 51% male) from a large academic medical center who underwent pre-dialysis placement of an AV fistula (286) or AV graft (94). The study quantified three endpoints: time from access placement to initiation of dialysis, likelihood of starting hemodialysis without a catheter, and number of vascular access procedures prior to dialysis initiation.
Results: The eGFR at access surgery was <10, 10-14 and >15 ml/min/1.73 m2 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/1.73 m2, 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 vs an AV fistula when the eGFR was <10 ml/min/1.73 m2 [88 vs 43%; OR 9.10, (95% CI 2.74-26.4)] and when the eGFR was 10-14 ml/min/1.73 m2 [88 vs 54%; OR 6.05 (2.35-15.0)], but similar when the eGFR was >15 ml/min/1.73 m2 [90 vs 75%; OR 3.00 (0.48-34.9)]. Patients undergoing an AV fistula were more likely to undergo an angioplasty (11 vs 0%, p<0.001), surgical access revision (26 vs 8%, p<0.001), a second access placement (16 vs 6%, p=0.02), and a catheter insertion (32 vs 11%, p<0.001).
Conclusions: Among patients with chronic kidney disease undergoing vascular access surgery when their eGFR was <15 ml/min/1.73 m2, catheter use at dialysis initiation was much less likely when an AV graft, rather than an AV fistula, was placed.
Reference:
Allon M, Al-Balas A, Young CJ, Cutter GR, Lee T. Predialysis Vascular Access Placement and Catheter Use at Hemodialysis Initiation. Clin J Am Soc Nephrol. 2023 Oct 16. doi: 10.2215/CJN.0000000000000317. Epub ahead of print. PMID: 37843844.