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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 3  |  Page : 384-388
High Failure Rate of First Arterio-Venous Fistula in Patients Starting Hemodialysis Treatment: A Report from the Ivory Coast


Service of Nephrology, Hypertension and Hemodialysis, Yopougon Teaching Hospital, P O Box 632 Abidjan 21, Ivory Coast

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   Abstract 

This study was conducted in order to identify the failure rate of the first arterio­venous fistula (AVF) in patients starting hemodialysis (HD) with a central venous catheter (CVC) and to search for factors responsible for this failure. A retrospective study was conducted on 85 patients on chronic HD in Abidjan, from March 15 th to April 15 th , 2007. Factors that could poten­tially influence the failure of the first AVF were collected. Statistical analysis was used for com­parison between groups. Among the study subjects, 7.14% had AVF at the start of their dialysis as against 92.86% who had CVC. About 50% of the patients starting dialysis with CVC failed to have an AVF created within 90 days of commencing dialysis. The number of catheters inserted was significantly higher in patients with failed first AVF as compared to their counterparts (49.29 % versus 30.77%) (p< 0.001). Similarly, the number of attempts at AVF creation, within 90 days of starting HD, was significantly higher in patients with failed first AVF (81.48% versus 18.52%) (p< 0.001). Multivariate analysis did not reveal any specific factor(s) that influenced the failure rate of the first AVF. Our study suggests that a very small number of patients in Ivory Coast started dialysis with an AVF. The failure rate of the first AVF in patients starting dialysis on CVC is about 50%.

Keywords: Arterovenous fistula, Central venous catheter, Hemodialysis, Ivory Coast

How to cite this article:
Ackoundou-N'Guessan C, Gnionsahe A, Guei M, Sayegh M, Kossi S, TIA M, Sissoko DL. High Failure Rate of First Arterio-Venous Fistula in Patients Starting Hemodialysis Treatment: A Report from the Ivory Coast. Saudi J Kidney Dis Transpl 2008;19:384-8

How to cite this URL:
Ackoundou-N'Guessan C, Gnionsahe A, Guei M, Sayegh M, Kossi S, TIA M, Sissoko DL. High Failure Rate of First Arterio-Venous Fistula in Patients Starting Hemodialysis Treatment: A Report from the Ivory Coast. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Dec 5];19:384-8. Available from: https://www.sjkdt.org/text.asp?2008/19/3/384/40497

   Introduction Top


Native arterio-venous fistula (AVF) repre­sents the gold standard of hemodialysis (HD) vascular access, since it is associated with less infection and offers good dialysis adequacy. Therefore, the creation of an AVF in patients with end-stage renal disease (ESRD) remains one of the good practice measures as recommended by the K/DOQI guidelines. [1] Patients with ESRD are often referred late to the specialist. The treatment of such patients necessitates the insertion of a HD catheter, which is well known to be frequently associated with severe infection. Consequently, these catheters have to be replaced by an AVF as early as possible. In the United States, it has been reported that 59.4% of patients failed to have an AVF within 90 days of starting dialysis and fac­tors like black race, female gender and late patient referral have been reported to in­fluence the success or the failure rate of the first AVF. [2] In developing countries, such studies are lacking.

Maintaining the patency of an AVF after the start of regular dialysis depends on a number of factors. The present study is aimed at highlighting a strategy to increase the success rate of the first AVF in a patient who starts dialysis with a central venous catheter (CVC). In developing countries, the financial implications of failure to create an AVF could be dismal for a population al­ready subjected to many ordeals. Indeed, catheter related infection and AVF recrea­tion could lead to further expenses. There­fore, successfully creating the first AVF in these patients is of paramount importance.


   Patients and Methods Top


A retrospective analysis of a cohort of 85 patients on chronic HD in different centers throughout the capital, Abidjan, Ivory Coast was undertaken from March15 th to April 15 th , 2007. Only adult patients of both sexes, and those who accepted to take part in the study were involved in the study. Patients who had started their dialysis outside the country were excluded. All study patients had either an AVF or CVC at the beginning of dia­lysis. The medical charts of the study pa­tients were reviewed for information on fac­tors likely to influence the failure or success of the first AVF. The following parameters were noted: age, sex, dry weight, cardiovas­cular risk factors (diabetes, hypertension, arterio-sclerosis), occupation, date of inser­tion of the first catheter, different sites of CVC insertion since the beginning of dia­lysis, total duration on dialysis, the number of CVCs inserted before the creation of an AVF, different complications related to use of CVCs, different sites of AVF creation, the number of attempts at AVF creation and their respective dates, and the date of use of the first AVF. The proportion of patients with AVF at the start of dialysis was noted. Patients who had their first AVF success­fully created after being on dialysis with CVC as also those who still had a CVC were studied. Factors likely to influence the success­ful creation of the first AVF were studied.


   Statistical analysis Top


Parameters are expressed in percentage or mean ± SD. Comparison between qualita­tive variables was made with the chi-square test or the Fischer exact test. Comparison between quantitative variables was done using the student's T test or the Mann-Whitney test. A p value < 0.05 was considered as signi­ficant. The time to conversion of a CVC to an AVF was analyzed using the Kaplan Meier method. Factors likely to influence this conversion were investigated with a multivariate analysis using the Cox model.


   Results Top


The mean age of the study patients was 41.55 ± 12.96 years and 75% of them were males. The mean duration on dialysis was 718.8 ± 988.9 days. The time to creation of the AVF after starting dialysis was 136.27 ± 151.45 days. The site preferred for CVC in­sertion was the internal jugular vein (IJV) in 63.64% of the cases, while the subcla­vian vein was used in 4.67% and the femo­ral vein in 31.79% of the cases. The pre­ferred site of AVF creation was a left radial anastomosis (LRA) in 82.89% of the cases [Table - 1]. Among these subjects, 7.14% had AVF at the start of their dialysis versus 92.86% who had CVCs initially. About 50% of the patients starting dialysis with CVC failed to have a successful AVF created within 90 days [Figure - 1]. On univariate ana­lysis, comparison between patients with failed AVF and those with successful AVF, showed that the number of catheters in­serted was significantly higher in the former group (49.29% versus 30.77%) (p< 0.001). The number of attempts for AVF creation within a period of 90 days was also signi­ficantly higher in the former than the latter group (81.48% versus 18.52%) (p< 0.001) [Table - 2]. None of the factors investigated appeared to be responsible for the high failure rate of AVF within the period of 90 days, by multi-variate analysis.


   Discussion Top


About 150 patients are on chronic HD in the Ivory Coast, which may reflect the limited capacity for HD in our country. In a dialysis unit, cardiovascular disease and catheter related infection remain the major causes of mortality. The incidence of cathe­ter related infection in HD units in Black Africa is not well known. In Europe, the prevalence of catheter-related infection is estimated at 16% which corresponds to 6.5 episodes per 1000 catheter days. [3] In Nigeria, the prevalence is estimated to be about 28% over a period of eight days to 11 weeks. [4] In our study, 25% of our patients presented with catheter-related infection during a pe­riod of five months. Infection remains therefore, frequent in the HD setting. After 90 days of being on dialysis, only 50 % of our study patients were with an AVF. In a study by Wasse et al [2] in the USA, most of the patients starting dialysis with a CVC (59.4%) failed to have an AVF created with­ in 90 days. In Italy [5] though, 75% of the patients had their AVF created within 90 days. Therefore, factors responsible for the failure of an AVF are variable from one country to another. The various factors that have been reported to be responsible for AVF failure are: black race, women, elderly patients, late patient referral and cardiovas­cular co-morbidities. [2] Indeed, our study pa­tients are all blacks and most of them are referred late to the nephrologist, explaining the high prevalence of patients with CVC at the start of dialysis. Others factors might also have contributed to the high rate of AVF failure. They include lack of radio­logical investigation of the vascular network before the creation of an AVF in our daily practice. Since most of our patients are not covered by any insurance, only clinical investigations are made to avoid extra ex­penditure. Another factor could be the high cost of the vascular access surgery in our country. Indeed, the cost of surgery is esti­mated to be around 300-450 Euros in a country where the average wage is about 150 Euros. Consequently, patients are referred late to the surgeon for vascular access crea­tion. In the meantime, the patient is sub­jected to multiple venous punctures. Indeed, the patient who remains dependant on a CVC is likely to experience catheter related infections. He gets hospitalised repeatedly where he could be subjected to random venous punctures with no regard towards preservation of veins as per the guidelines currently applied in the nephrology setting. This may lead to exhaustion of peripheral veins that could explain the high failure rate of AVF in our setting.

In our study, cardiovascular risk factors did not appear to promote AVF failure because our patients were very young and it is unlikely that such patients could develop peripheral vascular disease. However, de­tailed objective analysis was not made to substantiate this observation


   Conclusion Top


In conclusion, more than 92% of our study patients started dialysis using a CVC. This may be due to late referral. About 50% of the CVC were converted to AVF within a period of 90 days of starting HD. Vascular access investigation using radiological tools, reducing the cost of vascular access surgery and early referral of patients with ESRD could help in decreasing the failure rate of the first AVF in Ivory Coast.

 
   References Top

1.Eknoyang G, Levin NW, Eschbach JW, et al. Continuous quality improvement: DOQI becomes K/DOQI and is updated. National Kidney Foundation's Dialysis Outcome Quality Initiative. Am J Kidney Dis 2001; 37(1):179-94.  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.Kairaitis LK, Gottlieb T. Outcome and complications of temporary haemodialysis catheters. Nephrol Dial Transplant 1999;14 (7):1710-4.  Back to cited text no. 3    
4.Arogundade FA, Sanusi AA, Badmus TA, Ibrahim A, Akinsola A. Internal Jugular and subclavian catheterisation: Indication, problems and prospects in a Nigerian dialysis centre. Niger Postgrad Med J 2006; 13(1):26-30.  Back to cited text no. 4    
5.Di Benedetto A, Basci A, Cesare S, Marcelli D, Ponce P, Richards N. Increased use of catheters as vascular access: Is it justified by patients' clinical conditions? J Vasc Access 2007;8(1):21-7.  Back to cited text no. 5    

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Correspondence Address:
Clement Ackoundou-N'Guessan
Service of Nephrology, Hypertension and Haemodialysis, Yopougon Teaching Hospital, P.O. Box 632, Abidjan 21
Ivory Coast
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PMID: 18445897

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    Tables

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    Abstract
    Introduction
    Patients and Methods
    Statistical analysis
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