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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 83-87
Predictors of early vascular-access failure in patients on hemodialysis


Department of Nephrology, Dialysis and Kidney Transplantation, Military Teaching Hospital Mohammed V, Rabat, Morocco

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Date of Web Publication3-Jan-2012
 

   Abstract 

Vascular access management is key and critical in the successful management of hemodialysis patients, and an arteriovenous fistula (AVF) is considered the access of choice. This study was conducted between January 2007 and October 2009 at the Military Hospital in Rabat. Data on 115 patients who underwent 138 AVFs were retrospectively studied. Wrist AVF was the most common site of use. The primary course was uncomplicated in 63% of the patients, while primary failure occurred in 23.9% of the patients. Presence of diabetes was the most important risk factor for primary failure.

How to cite this article:
Bahadi A, Hamzi M A, Farouki M R, Montasser D, Zajjari Y, Arache W, Hassani K, El Amrani M, Alayoud A, Hassani M, Benyahia M, Elallam M, Elkabbaj D, Oualim Z. Predictors of early vascular-access failure in patients on hemodialysis. Saudi J Kidney Dis Transpl 2012;23:83-7

How to cite this URL:
Bahadi A, Hamzi M A, Farouki M R, Montasser D, Zajjari Y, Arache W, Hassani K, El Amrani M, Alayoud A, Hassani M, Benyahia M, Elallam M, Elkabbaj D, Oualim Z. Predictors of early vascular-access failure in patients on hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Sep 21];23:83-7. Available from: http://www.sjkdt.org/text.asp?2012/23/1/83/91307

   Introduction Top


In order to carry out hemodialysis (HD) successfully, vascular access management is key and critical. The native arterio-venous fistula (AVF) is currently considered the vascular access of first choice. The primary requirement of a vascular access is that it should allow sufficient blood flow, and remains the cornerstone of the administration of HD treatment. Additionally, it should be simple, reliable and durable. Brescia and Cimino [1] were the first to describe the surgical procedure of creating an AVF by performing an anastomosis of the radial artery and cephalic vein. HD techniques have consequently evolved rapidly.

End-stage renal disease (ESRD) is a major public health problem, the incidence of which is increasing every year. It is associated with significant morbidity and mortality, and incurs a huge financial cost, of which a significant portion is directly related to vascular access, not only related to complications of the procedures themselves, but also for management of thrombotic events or infections of different blood accesses. [2]

A native AVF (as originally described by Brescia and Cimino) is now considered the first choice vascular access, since the incidence of thrombotic or infectious complications is lower compared with other types of vascular access. Availability of an AVF at the time of commencement of dialysis directly reduces mortality in patients undergoing HD. [3]

A major campaign was initiated by the American Association National Kidney Foundation with support from the National Institute of Health (NIH) to promote the successful creation of this type of vascular access. This led to the development of clinical guidelines [The National Kidney Foundation Kidney Diseases Outcomes Quality Initiative (NKF K/DOQI) clinical practice guidelines], which is regularly updated and widely followed by centers worldwide. [4] However, most centers reported difficulty in achieving the targets set by these recommendations. Among the difficulties encountered, the AVFs are often complicated by early failure, including improper maturing or early thrombosis (before use), [5],[6],[7] delaying the availability of adequate vascular access, which is often described as the "Achilles heel" of HD.

This work presents a retrospective clinical study that was aimed to identify risk factors for early failure of native AVFs in the HD population.


   Materials and Methods Top


Data of all AVFs created between January 2007 and October 2009 in the service of Nephrology, Dialysis and Kidney Transplantation at the Military Hospital in Rabat were retrospectively collected. Data collected included demographics (gender, ethnicity, age at the creation of AVF), history of renal disease (etiology, duration of dialysis prior to completion of the AVF), presence of diabetes, characteristics of AVF (date of creation, site of creation; distal radiocephalic or proximal brachio-cephalic or brachiobasilic and expertise of the surgeon) and the use of a pre-operative echo-Doppler. Laboratory data were also collected at the time of creation of AVF (hemoglobin, C-reactive protein, albumin).

Early failure was defined as primary non-function due to thrombosis (before puncturing) or non-maturation, and the statistical analyses were performed by the program SPSS 15.0.


   Statistical Analysis Top


Statistical analysis consisted of searching for clinical and/or biological factors that are significantly associated with primary failure; the results of this comparison are shown in [Table 1]. On univariate analysis, we identified three risk factors: diabetes mellitus, distal location of AVF and hypo-albuminemia. However, on multivariate analysis, only two risk factors, namely diabetes and distal location, were significantly associated with primary failure in the population studied.
Table 1: Comparison between the patients with or without early failure by student and Khi-deux (X2) tests.

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   Results Top


During the study period, 115 patients with ESRD underwent creation of 138 native AVFs. Their clinical and laboratory features are summarized in [Table 2]. The cause of chronic renal failure was dominated by diabetes, as shown in [Figure 1].
Figure 1: Cause of initial nephropathy in the study patients.

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Table 2: Characteristics of the study patients.

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The use of central venous catheterization for HD was necessary in 58% of the patients, which was used for an average of 10 days before creating the AVF. The exploration of the venous system consisted of clinical examination and radiography of the upper limbs. Further radiological studies (Doppler or venography) were required in 14.3% of the patients. A total of 138 AVFs were created, including nine prosthetic grafts. The site of creation of the AVFs is shown in [Figure 2]. The post-operative course was uncomplicated in 63% of the cases [Figure 3], and primary failure was recorded in 33 cases (23.9%).
Figure 2: Distribution of the location of the arterio-venous fistula in the study patients.

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Figure 3: Complications seen in the arterio-venous fistulas in the study patients.

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   Discussion Top


The management of chronic renal failure has been made difficult due to delayed referral of uremic patients to the nephrologist. In our study, 43% of the patients were followed-up until they were discharged from HD after an average of five months.

The overall incidence of early failure of AVFs was 23.9%, which is similar to other published series (23-53%). [6],[7],[8],[9],[10] Two risk factors were identified: diabetes and distal site of creation of AVF.

A distal AVF carries the highest occurrence of early failure in several series. This is mainly due to vessels of smaller caliber and damage to the vessel wall due to frequent venipunctures. In our series, the presence of diabetes was a significant risk factor for the occurrence of early failure of AVF. This can be explained by the high prevalence of peripheral arterial disease in this population. Calcification of the blood vessels also seems to play a role in early failure of AVF due to reduced arterial compliance and impaired arterial dilation necessary for the maturation of a fistula. [11],[12],[13],[14],[15],[16],[17] Furthermore, diabetes is associated with endothelial dysfunction and an overall increase in oxidative stress, [13] which may explain the increased incidence of thrombotic events.

Systematic exploration of the upper limb before the creation of a vascular access may reduce, significantly, the risk of primary failure according to Branger. [18] However, we could not demonstrate in our series any benefit of the use of pre-operative Doppler study. This is probably explained by the small number of patients studied and the lack of standardized criteria.

Similarly, antiplatelet therapy, anticoagulation, or use of statins does not appear to influence the occurrence of early failure. However, this is a retrospective observational study, and only a randomized controlled interventional study would allow firm conclusions. Such studies, however, are difficult to perform in this population in which treatment protocols vary widely.

Our study data are useful in making an inventory for the management of vascular access for HD in our center, and shows results similar to other international series in terms of incidence of early failures. It is however possible to improve on these results. It has already been demonstrated that the development of a strategy toward planning for an AVF improves the quality of care of HD patients. [9],[10] The fistula must be created early before HD is required and patients at high risk, such as diabetes, must be referred to the nephrologist early.

 
   References Top

1.Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;275(20):1089-92.  Back to cited text no. 1
    
2.Feldman HI, Kobrin S, Wasserstein A. Hemodialysis vascular access morbidity. J Am Soc Nephrol 1996;7(4):523-35.  Back to cited text no. 2
    
3.Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in US hemodialysis patients. Kidney Int 2001;60(4):1443-51.  Back to cited text no. 3
    
4.NKF K/DOQI Guidelines. Clinical Practice Guidelines and Clinical Practice Recommendations. 2006 Updates. Hemodialysis Adequacy, Peritoneal Dialysis Am J Kidney Dis 2006; 48(Suppl 1):S176-S276.  Back to cited text no. 4
    
5.Adequacy and Vascular Access. The National Kidney Foundation, 2006 (http://www.kidney.org/professionals/KDOQI/guideline_upHD_PD_V A/index.htm).  Back to cited text no. 5
    
6.Allon M, Lockhart ME, Lilly RZ, et al. Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney Int 2001;60(5):2013-20.  Back to cited text no. 6
    
7.Dixon BS, Novak L, Fangman J. Hemodialysis vascular access survival: upper-arm native arteriovenous fistula. Am J Kidney Dis 2002; 39(1):92-101.  Back to cited text no. 7
    
8.Miller PE, Tolwani A, Luscy CP, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int 1999;56(1):275-80.  Back to cited text no. 8
    
9.Miller A, Hölzenbein TJ, Gottlieb MN, et al. Strategies to increase the use of autogenous arteriovenous fistula in end-stage renal disease. Ann Vasc Surg 1997;11(4):397-405.  Back to cited text no. 9
    
10.Miller CD, Robbin ML, Allon M. Gender differences in outcomes of arteriovenous fistulas in hemodialysis patients. Kidney Int 2003;63(1):346-52.  Back to cited text no. 10
    
11.Oliver MJ, McCann RL, Indridason OS, Butterly DW, Schwab SJ. Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas. Kidney Int 2001;60(4):1532-9.  Back to cited text no. 11
    
12.Roy-Chaudhury P, Sukhatme VP, Cheung AK. Hemodialysis vascular access dysfunction: A cellular and molecular viewpoint. J Am Soc Nephrol 2006;17(4):1112-27.  Back to cited text no. 12
    
13.Wong V, Ward R, Taylor J, Selvakumar S, How TV, Bakran A. Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg 1996;12(2):207-13.  Back to cited text no. 13
    
14.Meerarani P, Badimon JJ, Zias E, Fuster V, Moreno PR. Metabolic syndrome and diabetic atherothrombosis: Implications in vascular complications. Curr Mol Med 2006;6(5):501-14.  Back to cited text no. 14
    
15.Konner K. Primary vascular access in diabetic patients: an audit. Nephrol Dial Transplant 2000;15(9):1317-25.  Back to cited text no. 15
    
16.Ravani P, Marcelli D, Malberti F. Vascular access surgery managed by renal physicians: the choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 2002;40(6): 1264-76.  Back to cited text no. 16
    
17.Malovrh M. Vascular access for hemodialysis: arteriovenous fistula. Ther Apher Dial 2005;9 (3):214-7.  Back to cited text no. 17
    
18.Branger B, Granolleras C, Dauzat M, et al. Frequency of arteriovenous fistula on hemodialysis patients: two surveillance methods Doppler and dilution ultrasound techniques. Néphrologie 2004;25(1):17-22.  Back to cited text no. 18
    

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Correspondence Address:
A Bahadi
Department of Nephrology, Dialysis and Kidney Transplantation, Military Teaching Hospital Mohammed V, Rabat
Morocco
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PMID: 22237224

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    Figures

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    Tables

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