Temporal trends in hemodialysis access creation during the fistula first era.

OBJECTIVE: Although forearm arteriovenous fistulas (AVFs) are the preferred initial vascular access for hemodialysis based on national guidelines, there are no population-level studies evaluating trends in creation of forearm vs upper arm AVFs and arteriovenous grafts (AVGs). The purpose of this study was to report temporal trends in first-time permanent hemodialysis access type, and to assess the effect of national initiatives on rates of AVF placement. METHODS: Retrospective cross-sectional study (2012-2022) utilizing the Vascular Quality Initiative database. All patients older than 18 years with creation of first-time upper extremity surgical hemodialysis access were included. Anatomic location of the AVF or AVG (forearm vs upper arm) was defined based on inflow artery, outflow vein, and presumed cannulation zone. Primary analysis examined temporal trends in rates of forearm vs upper arm AVFs and AVGs using time series analyses (modified Mann-Kendall test). Subgroup analyses examined rates of access configuration stratified by age, sex, race, dialysis, and socioeconomic status. Interrupted time series analysis was performed to assess the effect of the 2015 Fistula First Catheter Last initiative on rates of AVFs. RESULTS: Of the 52,170 accesses, 57.9% were upper arm AVFs, 25.2% were forearm AVFs, 15.4% were upper arm AVGs, and 1.5% were forearm AVGs. From 2012 to 2022, there was no significant change in overall rates of forearm or upper arm AVFs. There was a numerical increase in upper arm AVGs (13.9 to 18.2 per 100; P = .09), whereas forearm AVGs significantly declined (1.8 to 0.7 per 100; P = .02). In subgroup analyses, we observed a decrease in forearm AVFs among men (33.1 to 28.7 per 100; P = .04) and disadvantaged (Area Deprivation Index percentile ≥50) patients (29.0 to 20.7 per 100; P = .04), whereas female (17.2 to 23.1 per 100; P = .03), Black (15.6 to 24.5 per 100; P < .01), elderly (age ≥80 years) (18.7 to 32.5 per 100; P < .01), and disadvantaged (13.6 to 20.5 per 100; P < .01) patients had a significant increase in upper arm AVGs. The Fistula First Catheter Last initiative had no effect on the rate of AVF placement (83.2 to 83.7 per 100; P=.37). CONCLUSIONS: Despite national initiatives to promote autogenous vascular access, the rates of first-time AVFs have remained relatively constant, with forearm AVFs only representing one-quarter of all permanent surgical accesses. Furthermore, elderly, Black, female, and disadvantaged patients saw an increase in upper arm AVGs. Further efforts to elucidate factors associated with forearm AVF placement, as well as potential physician, center, and regional variation is warranted.

A call to optimize haemodialysis vascular access care in healthcare disrupted by COVID-19 pandemic.

The COVID-19 pandemic has resulted in major disruption to the delivery of both routine and urgent healthcare needs in many institutions across the globe. Vascular access (VA) for haemodalysis (HD) is considered the patient's lifeline and its maintenance is essential for the continuation of a life saving treatment. Prior to the COVID-19 pandemic, the provision of VA for dialysis was already constrained. Throughout the pandemic, inevitably, many patients with chronic kidney disease (CKD) have not received timely intervention for VA care. This could have a detrimental impact on dialysis patient outcomes in the near future and needs to be addressed urgently. Many societies have issued prioritisation to allow rationing based on clinical risk, mainly according to estimated urgency and need for treatment. The recommendations recently proposed by the European and American Vascular Societies in the COVID-19 pandemic era regarding the triage of various vascular operations into urgent, emergent and elective are debatable. VA creation and interventions maintain the lifeline of complex HD patients, and the indication for surgery and other interventions warrants patient-specific clinical judgement and pathways. Keeping the use of central venous catheters at a minimum, with the goal of creating the right access, in the right patient, at the right time, and for the right reasons, is mandatory. These strategies may require local modifications. Risk assessments may need specific "renal pathways" to be developed rather than applying standard surgical risk stratification. In conclusion, in order to recover from the second wave of COVID-19 and prepare for further phases, the provision of the best dialysis access, including peritoneal dialysis, will require working closely with the multidisciplinary team involved in the assessment, creation, cannulation, surveillance, maintenance, and salvage of definitive access.

Gender-Based Utilization and Outcomes of Autogenous Fistulas and Prosthetic Grafts for Hemodialysis Access.

BACKGROUND: To evaluate gender-based patterns of utilization and outcomes of arteriovenous fistulas (AVFs) and grafts (AVGs) in a population-based cohort of hemodialysis (HD) patients. METHODS: A retrospective analysis of all patients in the United States Renal Data System who had an AVF or AVG placed for HD access (January 2007 to December 2014). Outcomes were access maturation, conduit patency, infection, and mortality. Chi-square, Student's t, Kaplan-Meier, and multivariable Cox regression analyses were employed accordingly. RESULTS: There were 456,693 (57%) males and 341,571 (43%) females who initiated HD via AVF (16%), AVG (4%) and HD catheter (80%). There was a 30% decrease in odds of initiating HD with AVF in females compared with males (adjusted odds ratio [aOR]: 0.70; 95% confidence interval [CI]: 0.69-0.71, P < 0.001). The use of HD catheter as a bridge to AVF was 36% higher in females compared with males (aOR: 1.36; 95% CI: 1.33-1.39, P < 0.001). Preemptive AVF maturation was 78% for males and 76% for females (P < 0.001). The risk-adjusted analyses showed a 7% decrease in AVF maturation comparing females with males (adjusted hazard ratio [aHR]: 0.93; 95% CI: 0.92-0.95, P < 0.001) but no difference in AVG maturation (aHR: 0.99; 95% CI: 0.97-1.01, P = 0.46) After risk adjustment, primary (AVF: aHR-0.87; AVG: aHR-0.96), primary-assisted (AVF: aHR-0.84; AVG: aHR-0.97), and secondary (AVF: aHR-0.85; AVG: aHR-0.98) patency were lower for females compared with males (all P < 0.05). Initiation of HD with a catheter and conversion to AVF was associated with lower patency in males (aHR: 0.29; 95% CI: 0.28-0.29; P < 0.001) and females (aHR: 0.31; 95% CI: 0.30-0.31; P < 0.001) compared with AVF initiates. Patient survival was higher for females compared with males who received AVF (aHR: 1.08; 95% CI: 1.07-1.09; P < 0.001) and AVG (aHR: 1.13; 95% CI: 1.11-1.15; P < 0.001). Initiation with HD catheter and subsequent conversion to AVF was associated with an increase in mortality for males (aHR: 1.45; 95% CI: 1.43-1.47; P < 0.001) and females (aHR: 1.44; 95% CI: 1.44-1.52; P < 0.001) compared with initiation via AVF. There was no significant difference in severe AVG infection comparing females with males (aHR: 1.05; 95% CI: 0.98-1.13; P = 0.16). CONCLUSIONS: Female gender is associated with a lower prevalence of preemptive AVF's, higher utilization of catheters as a bridge to AVF, and lower patency compared with males. There was no difference in access maturation but patient survival was higher for females compared with males.

Clinical outcomes in distal radial fractures with ipsilateral arteriovenous fistulas.

BACKGROUND: We evaluated the effects on arteriovenous fistula (AVF) function and clinical outcomes in patients given cast fixation, external skeletal fixation [ESF], or volar locking plate fixation [VLPF] for an ipsilateral distal radial fracture (DRF). METHODS: Thirteen patients were assigned to the surgery group or the cast group; follow-up was ≥12 months. One-year clinical outcomes and serial AVF function and radiographic outcomes were recorded and analyzed. RESULTS: All fractures were union and all AVFs were preserved with continuous hemodialysis. The surgery group had better immediately (radial inclination and articular step-off) and 1-year post-index procedure radiographic findings (radial height, radial inclination, volar tilting, ulnar variance, and articular step-off) and better 1-year functional outcomes (Mayo and QuickDASH score) than did the cast group. The VLPF subgroup had better QuickDASH scores and radiographic outcomes (radial inclination and ulnar variance) than did the ESF subgroup. CONCLUSIONS: One year after the index procedure, none of the treatment affected shunt function in DRFs ipsilateral to AVFs. ESF and VLPF yielded better functional and radiographic outcomes than did cast fixation in patients with ipsilateral DRFs and AVFs. LEVEL OF EVIDENCE: III.

Practice patterns in arteriovenous fistula ligation among kidney transplant recipients in the United States Renal Data Systems.

BACKGROUND: Arteriovenous fistulas (AVF) and grafts (AVG) have been associated with significant cardiac morbidity that often improves after ligation. However, AV access ligation after kidney transplant (KT) is controversial due to concern for potential long-term allograft failure. We investigated US trends in AV access ligation after KT and the association between ligation and allograft failure. METHODS: All adult Medicare patients on pretransplant hemodialysis with a functioning AVF or AVG who underwent first-time KT were studied using the United States Renal Data Systems (January 2011 to December 2013). Post-transplant AV access ligation was determined using current procedural terminology codes. The incidence of post-transplant AV access ligation was described, and characteristics for patients undergoing ligation vs no ligation were compared. Kaplan-Meier curves and Cox proportional hazard models were then used to determine the association of AV access ligation with long-term allograft failure and all-cause mortality after accounting for patient characteristics, donor characteristics, and variation in transplant center practices. RESULTS: A total of 16,845 patients with functioning AVF/AVG received a KT during the study period. Of these, 779 (4.6%) underwent post-transplant AV access ligation. The proportion of patients who underwent ligation varied substantially between transplant centers, ranging from 0% (43.0% of centers) to >10% (11.0% of centers). Transplant recipients who underwent access ligation were more likely to be female (40.4% vs 36.6%), had lower median body mass index (27.6 vs 28.4 kg/m2), spent longer on dialysis pretransplant (4.2 vs 4.0 years), and were less likely to have renal failure secondary to diabetes compared with other etiologies (25.0% vs 34.9%) (all, P ≤ .03). Patients who underwent ligation were also more likely to have steal syndrome (77.2% vs 4.1%) and AV access infectious or aneurysmal complications (2.7% vs 0.7%) (both, P < .001). After adjusting for donor and recipient characteristics, increasing age (adjusted hazards ratio [aHR], 1.01; 95% confidence interval [CI], 1.00-1.01), increasing years on dialysis (aHR, 1.06; 95% CI, 1.00-1.13), zero human leukocyte antigen mismatch (aHR, 1.82; [95% CI, 1.09-3.05), and steal syndrome (aHR, 41.00; 95% CI, 34.56-48.64) were associated with post-transplant AV access ligation. Black race (aHR, 0.82; 95% CI, 0.69-0.98) and congestive heart failure (aHR, 0.66; 95% CI, 0.54-0.82) were negatively associated with ligation. Three-year allograft failure occurred in 4.9% ± 1.3% transplant recipients who underwent access ligation vs 9.5% ± 0.5% transplant recipients with functioning access (log-rank, P = .30), and was not significantly different between groups after risk adjustment (aHR, 0.81; 95% CI, 0.47-1.40). There was also no significant association between AV access and all-cause mortality after risk adjustment (aHR, 0.84; 95% CI, 0.46-1.54). CONCLUSIONS: Post-transplant AV access ligation is uncommon and generally reserved for patients with steal syndrome. Importantly, ligation is not associated with post-transplant allograft failure, which occurs in less than 10% of patients at 3 years. There also appears to be no reduction in all-cause mortality with AV access ligation. These data suggest that AV access ligation after KT can likely be reserved for access-related complications because the systemic benefits appear to be minimal.

Diagnostic and Interventional Nephrology in Spain: A snapshot of current situation.

BACKGROUND:: Diagnostic and Interventional Nephrology has been a rising field in recent years worldwide. Catheter insertion, renal biopsy, renal ultrasound, and peritoneal dialysis catheter or permanent dialysis catheter insertion are vital to our specialty. At present, many of these procedures are delegated to other specialties, generating long waiting lists and limiting diagnosis and treatment. METHODS:: An online survey was emailed to all Nephrology departments in Spain. One survey response was allowed per center. RESULTS:: Of 195 Nephrology departments, 70 responded (35.8%). Of them, 72.3% (52) had ultrasound equipment, 77.1% insert temporary jugular catheters, and 92.8% femoral. Up to 75.7% (53 centers) perform native renal biopsies, of which 35.8% (19) are real-time ultrasound guided by nephrologists. Transplant kidney biopsies are done in 26 centers, of which 46.1% (12) by nephrologists. Tunneled hemodialysis catheters are inserted in 27 centers (38.5%), peritoneal catheter insertion in 18 (31.6%), and only 2 centers (2.8%) perform arteriovenous fistulae angioplasty. In terms of ultrasound imaging, 20 centers (28.5%) do native renal ultrasound and 16 (22.8%) transplanted kidneys. Of all units 71.4% offer carotid ultrasound to evaluate cardiovascular risk, only in 15 centers (21%) by nephrologists. AVF ultrasound scanning is done in 55.7% (39). CONCLUSION:: Diagnostic and Interventional Nephrology is slowly spreading in Spain. It includes basic techniques to our specialty, allowing nephrologists to be more independent, efficient, and reducing waiting times and costs, overall improving patient care. Nowadays, more nephrologists aim to perform them. Therefore, appropriate training on different techniques should be warranted, implementing an official certification and teaching programs.

No consensus on physicians' preferences on vascular access management after kidney transplantation: Results of a multi-national survey.

OBJECTIVE:: Arteriovenous fistulas for hemodialysis vascular access are a burden for the cardiovascular system. After successful kidney transplantation, prophylactic arteriovenous fistula ligation may improve cardiac outcomes; however, evidence is scarce. This survey investigates physicians' preference for management of arteriovenous fistulas and identifies the factors associated with preference for either arteriovenous fistula ligation or maintenance. MATERIALS AND METHODS:: A survey was sent to members of eight national and international Nephrology and Vascular Surgery societies. The survey comprised eight case vignettes of asymptomatic patients with a functioning arteriovenous fistula after kidney transplantation. Characteristics possibly associated with treatment preferences were arteriovenous fistula flow, left ventricular ejection fraction, and patient age. Respondents were asked to state preference to maintain or ligate the arteriovenous fistula. Linear mixed-effects models were used to investigate the association of treatment preference with case characteristics. RESULTS:: A total of 585 surveys were returned. A reduced left ventricular ejection fraction of 30% (beta 0.60, 95% confidence interval 0.55; 0.65) and a high flow of 2500 mL/min (beta 0.46, 95% confidence interval 0.41; 0.51) were associated with a higher preference for arteriovenous fistula ligation. Disagreement among respondents was considerable, as in four out of eight cases less than 70% of respondents agreed on the arteriovenous fistula management strategy. CONCLUSION:: Although respondents recognize a reduced left ventricular ejection fraction and a high flow as the risk factors, the high disagreement on management preferences suggests that evidence is inconclusive to recommend arteriovenous fistula ligation or maintenance after kidney transplantation. More research is needed to determine optimal arteriovenous fistula management after successful kidney transplantation.

A national study of autogenous arteriovenous access use and patency in a contemporary hemodialysis population.

OBJECTIVE: The predicted outcomes of autogenous arteriovenous (AV) hemodialysis access creation are predominantly based on historical data; however, both the hemodialysis population and clinical practices have changed significantly during the last decade. This study examined contemporary AV access clinical use and patencies. METHODS: A multicenter observational cohort study was performed of all new AV accesses created in Scotland in 2015. The primary end point was efficacy assessed by successful AV access use for a minimum of 30 days and primary, primary assisted, and secondary patency at 1 year. Data obtained included all interventions to maintain or to restore patency. Predictors of patency loss including demographics, comorbid conditions, dialysis status, AV access location, duplex ultrasound surveillance, procedures, prior access, and antiplatelets were assessed. Kaplan-Meier and competing risks analyses were performed to estimate the probability of AV access failure. All patients were followed up for at least 1 year or had a censoring event. RESULTS: A total of 582 AV accesses were created in 537 patients (mean age, 60 [standard deviation, 14] years; 60% men; 42% with diabetes) in nine adult renal centers. Mean follow-up was 11.8 (standard deviation, 7.6) months. By the end of the follow-up, 322 (55.3%) AV accesses were successfully used for dialysis. At 1 year, 48% (95% confidence interval [CI], 44-52) of AV accesses had primary patency, (95% CI, 63-71) had primary assisted patency, and 69% (95% CI, 65-73) had secondary patency. The leading cause of primary patency loss was primary failure (30%). An average of 0.48 intervention per patient-year was required to maintain patency. On multivariable analysis, patency was better for an upper arm than for a forearm AV access (1-year secondary patency of upper arm vs forearm AV accesses, 74% vs 58%). The cumulative hazard and incident functions for AV access failure were 31% (95% CI, 27-35) and 23% (95% CI, 20-27) at 1 year, respectively. CONCLUSIONS: Despite advances in recent years with preoperative vessel assessment and surveillance, patency rates have not improved, with primary failure remaining the major obstacle. Competing events should be taken into consideration; otherwise, biases may occur with overestimation of the probability of AV access failure.

Influence of arteriovenous fistula on daily living behaviors involving the upper limbs in hemodialysis patients: a cross-sectional questionnaire study.

BACKGROUND: Arteriovenous fistulae can restrict daily living behaviors involving the upper limbs in hemodialysis patients, but no studies have investigated the detailed effects of an arteriovenous fistula on routine life activities. Accordingly, many medical caregivers are unable to explain the effects of an arteriovenous fistula on daily life, particularly during non-dialysis periods, because they cannot observe them directly. METHODS: Thirty outpatients undergoing hemodialysis at 2 facilities scored the difficulty due to an arteriovenous fistula in performing 48 living behaviors during non-dialysis and 10 behaviors during dialysis into 5 grades in a comprehensive questionnaire survey. These behaviors were selected based on an open-answer pre-questionnaire administered to the 30 patients beforehand. The scores were also compared between dominant arm and non-dominant arm arteriovenous fistula groups. RESULTS: During non-dialysis, the difficulty scores of behaviors restricted out of concern for arteriovenous fistula obstruction (wear a wristwatch, hang a bag on the arm, carry a baby or a dog in the arms, wear a short-sleeved shirt, etc.) increased. The difficulties of "wear a wristwatch" and "hang a bag on the arm" were significantly higher in the non-dominant arm arteriovenous fistula group (both P < 0.05). In contrast, scores related to motor function (write, eat or drink, scratch an itch, etc.) increased remarkably during dialysis because of connection of the arteriovenous fistula to the dialysis machine. The difficulties of "write" and "eat or drink" were significantly higher in the dominant arm arteriovenous fistula group (both P < 0.05). CONCLUSIONS: Several key daily living behaviors restricted by an arteriovenous fistula were identified in this questionnaire survey. These results will be useful for pre-operative explanation of arteriovenous fistula surgery and arm selection in end-stage renal disease patients.

Utilization, patency, and complications associated with vascular access for hemodialysis in the United States.

BACKGROUND: This study examines the utilization and outcomes of vascular access for long-term hemodialysis in the United States and describes the impact of temporizing catheter use on outcomes. We aimed to evaluate the prevalence, patency, and associated patient survival for pre-emptively placed autogenous fistulas and prosthetic grafts; for autogenous fistulas and prosthetic grafts placed after a temporizing catheter; and for hemodialysis catheters that remained in use. METHODS: We performed a retrospective study of all patients who initiated hemodialysis in the United States during a 5-year period (2007-2011). The United States Renal Data System-Medicare matched national database was used to compare outcomes after pre-emptive autogenous fistulas, preemptive prosthetic grafts, autogenous fistula after temporizing catheter, prosthetic graft after temporizing catheter, and persistent catheter use. Outcomes were primary patency, primary assisted patency, secondary patency, maturation, catheter-free dialysis, severe access infection, and mortality. RESULTS: There were 73,884 (16%) patients who initiated hemodialysis with autogenous fistula, 16,533 (3%) who initiated hemodialysis with prosthetic grafts, 106,797 (22%) who temporized with hemodialysis catheter prior to autogenous fistula use, 32,890 (7%) who temporized with catheter prior to prosthetic graft use, and 246,822 (52%) patients who remained on the catheter. Maturation rate and median time to maturation were 79% vs 84% and 47 days vs 29 days for pre-emptively placed autogenous fistulas vs prosthetic grafts. Primary patency (adjusted hazard ratio [aHR], 1.26; 95% confidence interval [CI], 1.25-1.28; P < .001) and primary assisted patency (aHR, 1.36; 95% CI, 1.35-1.38; P < .001) were significantly higher for autogenous fistula compared with prosthetic grafts. Secondary patency was higher for autogenous fistulas beyond 2 months (aHR, 1.36; 95% CI, 1.32-1.40; P < .001). Severe infection (aHR, 9.6; 95% CI, 8.86-10.36; P < .001) and mortality (aHR, 1.29; 95% CI, 1.27-1.31; P < .001) were higher for prosthetic grafts compared with autogenous fistulas. Temporizing with a catheter was associated with a 51% increase in mortality (aHR, 1.51; 95% CI, 1.48-1.53; P < .001), 69% decrease in primary patency (aHR, 0.31; 95% CI, 0.31-0.32; P < .001), and 130% increase in severe infection (aHR, 2.3; 95% CI, 2.2-2.5; P < .001) compared to initiation with autogenous fistulas or prosthetic grafts. Mortality was 2.2 times higher for patients who remained on catheters compared to those who initiated hemodialysis with autogenous fistulas (aHR, 2.25; 95% CI, 2.21-2.28; P < .001). CONCLUSIONS: Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population.

Fifty years of hemodialysis access literature: The fifty most cited publications in the medical literature.

Objectives The modern era of hemodialysis access surgery began with the publication in 1966 by Brescia et al. describing the use of a surgically created arteriovenous fistula. Since then, the number of patients on chronic hemodialysis and the number of publications dealing with hemodialysis access have steadily increased. We have chronicled the increase in publications in the medical literature dealing with hemodialysis access by evaluating the characteristics of the 50 most cited articles. Methods We queried the Science Citation Index from the years 1960-2014. Articles were selected based on a subject search and were ranked according to the number of times they were cited in the medical literature. Results The 50 most frequently cited articles were selected for further analysis and the number of annual publications was tracked. The landmark publication by Dr Brescia et al. was unequivocally the most cited article dealing with hemodialysis access (1109 citations). The subject matter of the papers included AV fistula and graft (9), hemodialysis catheter (9), complications and outcomes (24), and other topics (8). Most articles were published in nephrology journals (33), with fewer in surgery (7), medicine (7), and radiology (3) journals. Of the 17 journals represented, Kidney International was the clear leader, publishing 18 articles. There has been an exponential rise in the frequency of publications regarding dialysis access with 42 of 50 analyzed papers being authored after 1990. Conclusion As the number of patients on hemodialysis has increased dramatically over the past five decades, there has been a commensurate increase in the overall number of publications related to hemodialysis access.

Temporal Trends, Determinants, and Outcomes of Inpatient versus Outpatient Arteriovenous Fistula Operations.

BACKGROUND: As high healthcare costs are increasing scrutinized, a movement toward reducing patient hospital admissions and lengths of stay has emerged, particularly for operations that may be performed safely in the outpatient setting. Our aim is to describe recent temporal trends in the proportion of dialysis access procedures performed on an inpatient versus outpatient basis and to determine the effects of these changes on perioperative morbidity and mortality. METHODS: The 2005-2008 American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary arteriovenous fistula (AVF) procedures using current procedural terminology codes. Changes in the proportions of inpatient versus outpatient operations performed by year, as well as the associated 30-day postoperative morbidity and mortality, were analyzed using univariable statistics and multivariable logistic regression. RESULTS: Two thousand nine hundred fifty AVF procedures were performed over the study period. Overall, 71.7% (n = 2,114) were performed on an outpatient basis. Inpatient procedures were associated with higher 30-day morbidity (10.5% vs. 4.5%) and mortality (2.8% vs. 0.7%) than outpatient procedures (both, P < 0.001). There was a significant increase in the proportion of procedures performed on an outpatient basis over time (2005: 56% vs. 2008: 75%; P < 0.001). There were no changes in postoperative morbidity or mortality for inpatient or outpatient AVF over time (P ≥ 0.36). Independent determinants of having an inpatient procedure included younger age (OR 0.99), increasing ASA class (ASA IV OR 1.56), congestive heart failure (OR 3.32), recent ascites (OR 3.25), poor functional status (OR 3.22), the presence of an open wound (OR 1.91), and recent sepsis (OR 6.06) (all, P < 0.01). Acute renal failure (OR 2.60) and current dialysis (OR 1.44) were also predictive (P < 0.001). After correcting for baseline differences between groups, the adjusted OR for both morbidity (aOR 1.93, 95% CI 1.38-2.69) and mortality (aOR 2.85, 95% CI 1.36-5.95) remained significantly higher for inpatient versus outpatient AVF. CONCLUSIONS: Dialysis access operations are increasingly being performed on an outpatient basis, with stable perioperative outcomes. Inpatient procedures are associated with worse outcomes, likely because they are reserved for patients with acute illnesses, serious comorbidities, and poor functional status. Overall, for appropriately selected patients, the movement toward performing more elective dialysis access operations on an outpatient basis is associated with acceptable outcomes.

Multi-Disciplinary Vascular Access Care and Access Outcomes in People Starting Hemodialysis Therapy.

BACKGROUND AND OBJECTIVES: Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates. RESULTS: We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively. CONCLUSION: Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures.

Variations in outcomes of hemodialysis vascular access by race/ethnicity in the elderly.

OBJECTIVE: Prevalence of end-stage renal disease, modality of treatment, and type of hemodialysis vascular access used varies widely by race/ethnicity in the United States, but outcomes of hemodialysis vascular access by race/ethnicity are poorly described. The objective of this study is to evaluate variations in outcomes of hemodialysis vascular access in the elderly by race/ethnicity. METHODS: Medicare outpatient, inpatient, and carrier files were queried from 2006 to 2011 for beneficiaries that were age ≥66 years and dialysis-dependent at time of index fistula/graft creation, qualified for Medicare by age only, and were continuously enrolled in Medicare 12 months before and after index fistula/graft creation. Primary outcome measures were early vascular access failure and 12-month failure-free survival, specifically, the variation in the difference between fistula and graft in non-White vs White race/ethnicity groups. RESULTS: Fistulas comprised a smaller proportion of index procedures performed in Blacks (65.9%; P < .001) and Asians (71.4%; P < .001), compared with Whites (78.0%) with no difference in Hispanics (78.7%; P = .59). Incidence of early failure after graft vs fistula was Whites, 34.9% vs 43.5% (P < .001), Blacks, 32.9% vs 49.1% (P < .001), Asians, 30.8% vs 40.5% (P = .014), and Hispanics 35.2% vs 43.2% (P = .005). The difference in early failure after fistula vs graft in Blacks was significantly larger than the difference in Whites (P < .001). The 12-month failure-free survival after index graft vs fistula was Whites 41.9% vs 38.9% (P = .008), Blacks 48.5% vs 37.3% (P < .001), Asians 51.6% vs 45.2% (P = .98), and Hispanics 51.9% vs 42.2% (P < .001). The difference in 12-month failure-free survival after graft vs fistula in Blacks and in Hispanics was larger than the difference in Whites (P < .001 and P = .02, respectively). CONCLUSIONS: Outcomes of fistulas vs grafts in the elderly vary significantly by race/ethnicity. The decreased risk of early failure after graft vs fistula creation is larger in Blacks compared with Whites. The higher failure-free survival at 12 months after graft vs fistula creation is larger in Blacks compared with Whites and trends toward being larger in Hispanics compared with Whites.

Interventional procedures and future drug therapy for hypertension.

Hypertension management poses a major challenge to clinicians globally once non-drug (lifestyle) measures have failed to control blood pressure (BP). Although drug treatment strategies to lower BP are well described, poor control rates of hypertension, even in the first world, suggest that more needs to be done to surmount the problem. A major issue is non-adherence to antihypertensive drugs, which is caused in part by drug intolerance due to side effects. More effective antihypertensive drugs are therefore required which have excellent tolerability and safety profiles in addition to being efficacious. For those patients who either do not tolerate or wish to take medication for hypertension or in whom BP control is not attained despite multiple antihypertensives, a novel class of interventional procedures to manage hypertension has emerged. While most of these target various aspects of the sympathetic nervous system regulation of BP, an additional procedure is now available, which addresses mechanical aspects of the circulation. Most of these new devices are supported by early and encouraging evidence for both safety and efficacy, although it is clear that more rigorous randomized controlled trial data will be essential before any of the technologies can be adopted as a standard of care.

New probing and warm-wash-out technique improves early patency rates in arteriovenous fistula surgery.

OBJECTIVE: Arteriovenous fistulas (AVFs) are commonly used during hemodialysis. Early failure of AVFs is quite common with incidence of 43% to 63%. In this study we aimed to describe a novel approach to AVF surgery for improving early patency rates. PATIENTS AND METHODS: Patients were divided into two groups according to use of probing and warm-wash-out technique. Group I consisted of 31 patients with additional probing technique. Group II consisted of 32 patients without additional maneuver. End-to-side anastomosis were used to all patients. Technical success was defined as having palpation of a thrill on fistula. Flow rates of draining vein was measured at 1st hour, 24th hour, 1st week and 3rd week of surgery. SURGICAL TECHNIQUE: Classical maneuvers were performed until end of the anastomosis. At this time, vein lumen was washed by low-dosed heparinized warm fluid, with assistance of a simple catheter. RESULTS: Technical success was similar in both groups at 1st hour and 24th hour, while there were significantly differences between groups at 1st week (p = 0.042) and 3rd week (p = 0.05) assessments. Flow rates were also measured significantly higher in Group I at 1st hour (p = 0.011) and 24th hour (p = 0.016). Flow rates were almost similar in two groups at 1st and 3rd weeks but overall success rate was higher in Group I comparing with Group II (96.8% vs. 81.3%, respectively, p = 0.05). CONCLUSIONS: Probing and warm-wash out technique will simply increase the surgical success and flow rate of draining vein.

Variability in anesthetic considerations for arteriovenous fistula creation.

INTRODUCTION: Anesthetic options for arteriovenous fistula (AVF) creation include regional anesthesia (RA), general anesthesia (GA) and local anesthetic for select cases. In addition to the benefits of avoiding GA in high-risk patients, recent studies suggest that RA may increase perioperative venous dilation and improve maturation. Our objective was to assess perioperative outcomes of AVF creation with respect to anesthetic modality and identify patient-level factors associated with variation in contemporary anesthetic selection. METHODS: National Surgical Quality Improvement Project (NSQIP) data (2007-2010) were accessed to identify patients undergoing AVF creation. Univariate analysis and multivariate logistic regression were performed to assess the relationships among patient characteristics, anesthesia modality and outcome. RESULTS: Of 1,540 patients undergoing new upper extremity AVF creation, 52% were male and 81% were younger than 75 years. Anesthesia distribution was GA in 85.2%, local/monitored anesthetic care (MAC) in 2.9% and RA in 11.9% of cases. By multivariate analysis, independent predictors of RA were dyspnea at rest (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.1-4.9), age >75 (HR 1.6, 95% CI 1.1-2.3) and teaching hospital status as indicated by housestaff involvement (HR 3.7, 95% CI 2.5-5.5). RA was associated with higher total operative time, duration of anesthesia, length of time in operating room and duration of anesthesia start until surgery start (p<0.01). There were no differences between perioperative complications or mortality among anesthetic modalities, although all deaths occurred in the GA group. DISCUSSIONS: Despite recent reports highlighting potential benefits of RA for AVF creation, GA was surprisingly used in the vast majority of cases in the United States. The only comorbidities associated with preferential RA use were advanced age and dyspnea at rest. Practice environment may influence anesthetic selection for these cases, as a nonteaching environment was associated with GA use. The trend seen here toward higher mortality in GA and the potential perioperative benefits of RA for the access should encourage more widespread use of RA in practice for this high-risk patient population.

Improving arteriovenous fistula rate: Effect on hemodialysis quality.

Vascular access (VA) is the lifeline for patients with end-stage renal disease on regular hemodialysis (HD). Tunneled catheters have been associated with increased risk of luminal thrombosis, infection, hospitalization, and high cost. Our aims were to follow the "Fistula First Initiative," avoid or reduce the rate of catheter insertion, improve the rate of arteriovenous fistula (AVF) use, and study the effect of increased AVF use on quality of dialysis and patient's outcome. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team to manage 358 patients who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation age of patients was 52 ± 15 years with 62% male patients. Over a period of 2 years, 408 procedures were performed. These include 293 AVFs and 56 arteriovenous grafts (AVGs). Other procedures include 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele, and ligation of 1 AVF. This program resulted in significant increase in AVF rate from 35% to 82%; reduction in catheter rate from 62% to 10.9%; infection rate down from 6.6% to 0.6%; VA clotting down from 5.1% to 1.0%; and increase in average blood flow rate from 214 ± 32 to 298 ± 37 mL/min (P < 0.01). These results have been associated with improved average single pool Kt/V from 0.88 ± 0.19 to 1.28 ± 0.2 (P < 0.01); increased hemoglobin from 9.2 ± 1.2 to 10.9 ± 0.9 g/dL (P < 0.01); improved serum albumin from 3.2 ± 0.5 to 3.7 ± 0.4 g/dL (P < 0.05); reduction in administered erythropoietin dose by 19%; and significant drop in hospitalization rate from 6.1% to 3.8%. These results confirm the great benefits of AVF on quality of HD and patient outcome, and clearly affirm that AVF should always be considered first.