TITLE:International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS).
RATIONALE &OBJECTIVE: Optimizing vascular access use is crucial for long-term hemodialysis patient care. Because vascular access use varies internationally, we examined international differences in arteriovenous fistula (AVF) patency and time to becoming catheter-free for patients receiving a new AVF.
STUDY DESIGN: Prospective cohort study.
SETTING & PARTICIPANTS: 2,191 AVFs newly created in 2,040 hemodialysis patients in 2009 to 2015 at 466 randomly selected facilities in the Dialysis Outcomes and Practice Patterns Study (DOPPS) from the United States, Japan, and EUR/ANZ (Belgium, France, Germany, Italy, Spain, Sweden, United Kingdom, Australia, and New Zealand).PREDICTORS:Demographics, comorbid conditions, dialysis vintage, body mass index, AVF location, and country/region.
OUTCOMES: Primary/cumulative AVF patency (from creation), primary/cumulative functional patency (from first use), catheter dependence duration, and mortality.ANALYTICAL
APPROACH: Outcomes estimated using Cox regression.
RESULTS: Across regions, mean patient age ranged from 61 to 66 years, with male preponderance ranging from 55% to 66%, median dialysis vintage of 0.3 to 3.2 years, with 84%, 54%, and 32% of AVFs created in the forearm in Japan, EUR/ANZ, and United States, respectively. Japan displayed superior primary and cumulative patencies due to higher successful AVF use, whereas cumulative functional patency was similar across regions. AVF patency associations with age and other patient characteristics were weak or varied considerably between regions. Catheter-dependence following AVF creation was much longer in EUR/ANZ and US patients, with nearly 70% remaining catheter dependent 8 months after AVF creation when AVFs were not successfully used. Not using an arteriovenous access within 6 months of AVF creation was related to 53% higher mortality in the subsequent 6 months.
LIMITATIONS: Residual confounding.
CONCLUSIONS: Our findings highlight the need to reevaluate practices for optimizing long-term access planning and achievable AVF outcomes, especially AVF maturation. New AVFs that are not successfully used are associated with long-term catheter exposure and elevated mortality risk. These findings highlight the importance of selecting the best access type for each patient and developing effective clinical pathways for when AVFs fail to mature successfully.
SOURCE: Pisoni RL, Zepel L, Zhao J, et al. International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS)[J]. Am J Kidney Dis, 2021, 77(2):245-254. DOI: 10.1053/j.ajkd.2020.06.020.
理论与目的：优化血管通路的使用对于长期血液透析患者的护理至关重要。由于血管通路的使用在国际上有所不同，我们检查了接受新动静脉内瘘(AVF)治疗的患者在动静脉内瘘(AVF)通畅率和无导管时间方面的国际差异。
研究设计：前瞻性队列研究。
地点和参与者：2009至2015年间，在来自美国、日本和EUR/ANZ(比利时、法国、德国、意大利、西班牙、瑞典、英国、澳大利亚和新西兰)的466个随机选择的DOPPS机构中，在2040名血液透析患者中新建了2191个AVF。
预测因素：人口统计学、合并症、透析年限、体重指数、AVF位置和国家/地区。
评估指标：初次/累积动静脉内瘘通畅率(建立时)、初次/累积功能通畅率(首次使用时)、导管依赖持续时间和死亡率。
分析方法：使用Cox回归估计结果。
结果：在不同地区，患者平均年龄从61岁到66岁不等，男性占55%到66%，透析年龄中位数为0.3到3.2年，日本、EUR/ANZ和美国分别有84%、54%和32%的动静脉内瘘发生在前臂。由于AVF的使用成功率较高，日本显示出卓越的初级和累积通畅率，而不同地区的累积功能通畅率相似。动静脉内瘘的通畅性与年龄和其他患者特征的相关性很弱，在不同地区之间差异很大。在EUR/ANZ和US患者中，AVF创建后对导管的依赖时间要长得多，当AVF没有成功使用时，近70%的患者在AVF创建后8个月仍然依赖导管。动静脉内瘘建立后6个月内未使用动静脉通路与随后6个月的死亡率增加53%相关。
局限性：残留混杂。
结论：我们的研究结果强调了重新评估优化长期通路规划和可实现的AVF结果的实践的必要性，特别是AVF的成熟度。未成功使用的新动静脉内瘘与长期导管暴露和死亡风险增加有关。这些发现强调了为每个患者选择最佳的通路类型，并针对动静脉内瘘未能成功成熟的情况开发有效的临床路径的重要性。
启发：地区不同，初始内瘘建立方式有所不同，但整体通畅率还是不错的，尽早使用内瘘可减少导管暴露时间，降低死亡风险。
