Saudi Journal of Kidney Diseases and Transplantation

: 2014  |  Volume : 25  |  Issue : 1  |  Page : 161--165

Factors affecting the maturation of arterio-venous fistula in patients with end-stage renal disease

Morteza Khavanin Zadeh1, Alireza Negahi2,  
1 Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
2 Rasool-e-Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran

Correspondence Address:
Morteza Khavanin Zadeh
Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran

How to cite this article:
Zadeh MK, Negahi A. Factors affecting the maturation of arterio-venous fistula in patients with end-stage renal disease.Saudi J Kidney Dis Transpl 2014;25:161-165

How to cite this URL:
Zadeh MK, Negahi A. Factors affecting the maturation of arterio-venous fistula in patients with end-stage renal disease. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2020 Jul 9 ];25:161-165
Available from:

Full Text

To the Editor ,

Chronic renal failure (CRF) is one of the most important problems in medicine, and remains one of the main causes of death caused by non-infectious diseases. [1] Hemodialysis (HD) has been the mainstay in the treat­ment of CRF. [2] Vascular access is an important pre-requisite to successfully perform HD, and has become one of the critical topics for medical researchers in nephrology. [3]

Despite the undeniable benefits of arterio-venous fistula (AVF) as a form of vascular access, considerable amount of time is re­quired for the fistula to mature and suitably develop into a functional format. [4],[5] Failure or success in maturation of AVFs depends on various factors; first, demographic factors such as race, age, geographical situation and finan­cial status; [6] second, routine diagnostic tests performed before surgery, such as Color Doppler sonography, for assessing the anatomical situation of arteries and veins; [7] third, assess­ment during operation, such as measuring the arterial flow and the diameter of the artery and vein; [8] and, lastly, the post-operative care and training for related specific exercises. [9] Fami­liarity with these factors will help in patient selection and best treatment protocol in order to make the AVF successful and minimize its maturation time. [10],[11]

This prospective cross-sectional study was performed in 2010-2011 at the Hasheminejad Kidney Center, the Tehran University of Medical Sciences, Tehran, Iran. The study popu­lation comprised end-stage renal disease pa­tients who needed HD and were referred to this hospital. Patients were then referred to a single surgeon who performed all AVFs du­ring the study period. Patients who were not available for follow-up after the surgery and those who did not have reliable medical his­tory were excluded from the study. During the study period, a total of 100 AVFs were made and these patients were assessed in detail.

The patients were first given a brief descrip­tion about the procedure and then an AVF creation form was filled out by each patient including the following information: Age, gen­der and medical history including risk factors for atherosclerosis (smoking habits, hyperten­sion, diabetes mellitus, dyslipidemia), cardio­vascular diseases (cerebrovascular disease, coronary artery disease and peripheral arterial disease), cause of CRF, any previous history of dialysis or AVF creation and any trauma or operation in the upper body compartment (tho­racic or cervical area). Patients who had failed fistulas previously were subjected to Color Doppler sonography for assessing the anato­mical situation of the arteries and veins.

After checking the blood pressure, pulse and presence of any edema, the patients underwent surgery using their proximal radial artery for anastomosis. A record was made of the rele­vant variants including the anastomosed ar­tery and vein, the AVF location (the ante-cubital area), use of heparin during the operation and presence of thrill or bruit following surgery.

After surgery, the patients were examined routinely every week and, after confirming that the AVF had matured, dialysis was star­ted. The time between the first successful HD and AVF creation was considered as the matu­ration time. Maturation of the AVF was judged based on the following: Physical evaluation such as the length of the straight superficial vein (10 cm), palpability with a diameter of 4 mm and continuous and uniform thrill and bruit on auscultation at the location of the anastomosis. Also, patients were routinely checked for side-effects of the AVF. If the AVF was still not mature for use within four months, it was called "immature AVF." HD was considered successful if adequate blood flow rate, determined by the responsible physi­cian, was achieved.

Descriptive quantification such as average, median and standard deviation were used to present the quantitative and qualitative varia­bles. Differences between the ratios were ana­lyzed by Chi-2 test and, for mean, the t-test was used. To predict the correlation between the quantitative variables, logistic regression testing was used. Statistical analysis was per­formed with SPSS software-15. P <0.05 was considered significant.

One hundred patients were included in this study. Four patients died during the study, seven had failure of AVF creation within the first month after operation, one had immature AVF and one other patient did not have a schedule reference to the center. Of the remai­ning 87 patients, 61 were male (70.1%) and 26 were female (29.9%), with an age range of 19- 87 years and a mean of 57 ± 16.5 years. The findings on general physical evaluation of the study patients are presented in [Table 1].{Table 1}

In our study, the average maturation time for the AVFs was 5.6 ± 2.4 weeks, with a range of 13-16 weeks. The correlation between the maturation time and the quantitative variables was studied and is presented in [Table 2]. A sig­nificant relationship with maturation time was found only with presence of ischemic heart disease (IHD) and diabetes.{Table 2}

The correlation between the maturation time and each of the quantitative variables is sum­marized in [Table 3]. There was a significant correlation between age of the patient and matu­ration time. Also, there was a significant negative correlation between the maturation time and the systolic and diastolic blood pressures during the surgery.{Table 3}

We found that patients with hemoglobin (Hb) concentrations ≤8 g/dL had an average matu­ration time of 6 ± 2.3 weeks and those with Hb above 8 g/dL had a maturation time of 5.1 ± 2.7 weeks (P = 0.109).

Also, our study showed that patients who had previous AVF creation and/or central venous catheter insertion on the same side had a mean maturation time of 4.6 ± 2.9 weeks and that those who had these procedures on the other side had a mean maturation time of 4.6 ± 1.8 weeks. The difference was not statistically significant (P = 0.961). Multivariate logistic regression showed that age and systolic and diastolic blood pressure during surgery had an independent and significant correlation with maturation time.

In the recent years, improvement in the diag­nosis and treatment of kidney diseases has led to an increase in the number of patients who undergo HD. Many of these patients are aged or have diabetes, hypertension, hyperlipidemia or atherosclerosis, which create different levels of vascular problems. This may result in in­ability of AVF creation or delayed or unsuc­cessful maturation of the fistula.

Our data indicate that most patients in our study were males and in the age range of 40- 70 years. Majority of them had background risk factors such as diabetes, hypertension and cardiovascular diseases, and most of them had undergone HD before. The mean maturation time was 5.6 ± 2.4 weeks; in five patients, the maturation time was three weeks and in one patient it was 16 weeks.

We found that age of the patient had a positive and significant correlation with matu­ration time. Patient's gender did not have any influence on maturation time, while presence of diabetes and IHD had a negative influence on the AVF maturation time. In our study, pre­sence of cerebrovascular diseases, use of heparin during surgery, previous AVF or central vein catheterization or previous HD did not have any effect on the AVF maturation time.

The patient's blood pressure during surgery had a negative correlation with AVF matu­ration time; thus, with higher systolic and diastolic blood pressure during surgery, the matu­ration time decreased, and vice versa. No sig­nificant correlation was found between the pre-operative Hb and the maturation time.

Our data show similarities and differences with previous studies. Feldman has reported that patients with higher age, history of cerebrovascular disease, transient ischemic attacks and those who needed HD at the time of surg­ery had a higher risk of unsuccessful AVF creation. On the other hand, use of heparin during AVF creation, larger vein diameter and mean arterial pressure above 85 mm Hg were associated with more successful AVF creation. [12] Another study has reported that there was no significant correlation between the maturation time and age, gender, diabetes and the diameter of the artery and vein. [13] The dis­crepancies in the data in this study with those presented earlier may be because of the diffe­rences in study tools and performance of physi­cal evaluations and also demographic factors.

Overall, this study shows that there are some factors that might delay the AVF maturation time and, therefore, the initiation of HD. These factors are patient's age, presence of diabetes and cardiovascular diseases. Taking these fac­tors into consideration, early referral for AVF surgery can help in avoiding central venous cannulation for HD pending AVF maturation.


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