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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 5  |  Page : 821-822
Failure Rate of First Arterio-Venous Fistula in a Developing Country


Department of Renal Transplant, St. Georges Hospital, London, United Kingdom

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How to cite this article:
Jahromi AH. Failure Rate of First Arterio-Venous Fistula in a Developing Country. Saudi J Kidney Dis Transpl 2008;19:821-2

How to cite this URL:
Jahromi AH. Failure Rate of First Arterio-Venous Fistula in a Developing Country. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Jul 15];19:821-2. Available from: http://www.sjkdt.org/text.asp?2008/19/5/821/42472
To the Editor,

We read with great interest the published report from Ivory Coast by Clement Ackoundou­N'guessan et al, about the failure rate of first arterio-venous fistula (AVF) in the patients starting haemodialysis treatment. [1] However; we have few queries for which clarification is required from the authors.

Early creation of AVF is necessary to avoid the risks and complications associated with the prolonged usage of central venous catheters (CVC) as an access for hemodialysis. As the authors have mentioned, previous reports have proposed factors like age, race, gender, history of peripheral vascular disease and ischemic heart disease as risk factors for an increase in failure rate of the first AVF, which con­sequently would increase the chance of pro­longed CVC dependence. [2]

It is mentioned that the number of CVC in­serted has been significantly higher in patients with failed AVF within 90 days of starting hemodialysis than those with successful AVF. (p< 0.001) It is also mentioned that the number of attempts for AVF creation within the period of 90 days was also significantly higher in patients with failed AVF within 90 days than those with successful AVF. (p< 0.001). [1]

First, it looks obvious for both of these facts to be present as in case of the patient with successful AVF within 90 days, there would not be any requirement for having further attempts of CVC insertion while the fistulae is functioning. Similarly, patient with successful AVF would not require having further attempts for AVF creation. We did not understand the significance of these two data.

Secondly, we would like some clarification with regards to the patients with repeated attempts of CVC insertion in the first 90 days of starting hemodialysis. It would be helpful to know what has been the cause for the failure of the CVC access in this group and what per­centage of that has been caused by line in­fection. It is mentioned in this study that 25% of the patients presented with catheter related infection during a period of five months. It is not clear what percentage of the failure in the 3 months period was due to infection.

Thirdly, lack of even basic radiological inves­tigation of the vascular network before crea­tion of AVF in this group of patients which according to the authors has been caused by lack of insurance cover for these studies should be balanced against the estimated cost of vascular access surgery in that region. The cost of surgery is estimated to be between 300­450 Euros according to the article. In this evaluation knowing the cost of the basic radiologic investigations might be helpful and justifiable at least in the patients with previous failed attempts of the AVF. We would appre­ciate clarification of the costs and availability of the radiologic investigations.

Fourthly, it is mentioned in the study that cardiovascular risk factors (hypertension and diabetes) did not appear to promote AVF failure as the patients has been young (Mean age = 41.55 + 12.96 years) and it is unlikely that such patients could develop peripheral vascular disease. It looks like that 90 days duration of follow up in these patients considering limited number of the cases in this study, has not been long enough for showing the difference in the outcome of the AVF in them.

We agree with the explanation of lower age of the patients with high cardiovascular risk in this study comparing to some other studies to be one of the reasons that a significant diffe­rence in the early outcome of AVF has not been shown in them. However, we believe number of patients studied and duration of study would be the two main factors, which would help showing the difference in the outcome of AVF even in the young group of high-risk patients.

Fifth, the total number of patients in this study has been mentioned initially to be 85. While adding the number of patients in the two subgroups with and without AVF as in Table II would come as 79.

Sixth, the impact of surgeons experience and surgical technique on the AVF success rate have been studied before. [3],[4] As the data in this report has been collected form different centres, it would require further clarification whether different surgical teams have been involved in different centres and what level of expertise they have had. It would be helpful to know what has been the surgical technique used for creation of AVF in these patients.

We would like to thank the authors for this interesting paper highlighting the importance and actual challenging situation of vascular access for the patients with renal failure in the developing countries.

 
   References Top

1.Ackoundou-N'guessan C, Gnionsahe A, Guei M, et al. High failure rate of first arterio-venous fistula in patients starting haemodialysis treatment: a report from the Ivory Coast. Saudi J Kidney Dis Transpl 2008;19(3):384-8.  Back to cited text no. 1    
2.Wasse H, Speckman RA, Frankenfield DL, Rocco MV, McClellan WM. Predictors of delayed transition from central venous catheter use to permanent vascular access among ESRD patients. Am J Kidney Dis 2007;49(2):276-83.  Back to cited text no. 2    
3.Fassiadis N, Morsy M, Siva M, Marsh JE, Makanjuola AD, Chemla ES. Does the surgeon's experience impact on radiocephalic fistula patency rates? Semin Dial 2007;20(5):455-7.  Back to cited text no. 3    
4.Zarin M, Ahmad I, Waheed D, et al. Arterio­venous fistula construction in chronic hemo­dialysis patients: Comparison of end-to-side and side-to-side techniques. J Coll Physicians Surg Pak 2004;14(10):619-21.  Back to cited text no. 4    

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Correspondence Address:
Alireza Hamidian Jahromi
Department of Renal Transplant, St. Georges Hospital, London
United Kingdom
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PMID: 18711308

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