TITLE: Factors associated with functional arteriovenous fistula at hemodialysis start and arteriovenous fistula non-use in a single-center cohort.

BACKGROUND: The gold standard of commencing hemodialysis with a functional arteriovenous fistula (AVF) is challenging. We aim to review factors associated with functional AVF at hemodialysis start at a tertiary hospital.

METHODS: We retrospectively reviewed incident hemodialysis patients or who had AVF creation at a single tertiary hospital from 2011 to 2016. Data was extracted for patient comorbidities, duration from referral to AVF creation and hemodialysis start, estimated glomerular filtration rate (eGFR) at surgical referral, referring nephrologist, events accelerating eGFR decline, and revisions for "failing to mature" AVF to assess factors associated with non-functioning AVF or late AVF creation, using multinomial logistic regression.

RESULTS: Two hundred two patients received hemodialysis and 51 had AVF creation but did not dialyze (AVF futility rate 20%). Of these, 133 (66%) commenced hemodialysis with a central venous catheter (CVC) and 69 (34%) with an AVF. Patients with functional AVFs at hemodialysis start were referred earlier than those with non-functional AVFs (median 256 vs 66 days before hemodialysis start, p = 0.001). Age, sex, eGFR at surgical referral, and comorbidities were not predictive of patients with functional AVFs. Events accelerating eGFR decline were associated with an increased incidence of CVC at hemodialysis start (risk ratio (RR) 4.21, 95% confidence interval (CI) 1.96-9.03, p < 0.0001). Referring nephrologists external to our renal unit may be associated with non-functional AVF at hemodialysis start (RR 6.60, 95% CI 1.74-25.13, p = 0.006).

CONCLUSIONS: We found that functional AVFs required referral a median of 256 days prior to hemodialysis start and events accelerating eGFR decline increase the incidence of CVC at hemodialysis start. Age, sex, eGFR at surgical referral, and comorbidities did not inform the likelihood of timely AVF creation and evaluation of further predictive pre-dialysis factors is necessary to identify patients requiring early AVF creation whilst minimizing the cost of unnecessary procedures.

SOURCE: Chung EY, Knagge D, Cheung S, et al. Factors associated with functional arteriovenous fistula at hemodialysis start and arteriovenous fistula non-use in a single-center cohort[J]. J Vasc Access, 2021 :11297298211002574. DOI: 10.1177/11297298211002574.

背景:从功能性动静脉内瘘(AVF)启动血液透析的黄金标准具有挑战性。我们旨在回顾三级医院血液透析开始时与功能性AVF相关的因素。

方法:我们回顾性评估了2011年至2016年在一家三级医院进行血液透析的患者或建立AVF的患者。提取患者合并症、从转诊到建立AVF和血液透析开始的持续时间、手术转诊时估计的肾小球滤过率、转诊肾病学家、加速肾小球滤过率下降的事件以及“未成熟”AVF的修补，使用多项逻辑回归评估与无功能AVF或较晚建立AVF相关的因素。

结果:202例患者接受了血液透析，51例建立AVF但未透析(AVF无效率20%)。其中，133人(66%)开始使用中心静脉导管进行血液透析，69人(34%)使用AVF进行血液透析。血液透析开始时有功能性AVF的患者比无功能性AVF的患者转诊时间更早(血液透析开始前的中位数为256天 vs 66天，p = 0.001)。年龄、性别、手术转诊时的eGFR和合并症不能预测功能性AVF患者。加速eGFR下降的事件与血液透析开始时心血管疾病的发生率增加有关(风险比4.21，95%置信区间1.96-9.03，p < 0.0001)。在血液透析开始时，我们肾脏科以外的肾病专家转介可能与无功能AVF相关(相对风险6.60，95%可信区间1.74-25.13，p = 0.006)。

结论:我们发现功能性动静脉内瘘需要在血液透析开始前平均256天进行转诊，加速eGFR下降的事件增加了血液透析开始时心血管疾病的发生率。年龄、性别、手术转诊时的eGFR和合并症并未预示及时建立AVF的可能性，需要对未来预测性透析前因素进行评估，以确定需要早期建立AVF的患者，同时最大限度地减少不必要的手术成本。

启发：紧急进入透析与心血管事件发生有一定关系；过早建立内瘘可能伴无效内瘘的产生；过晚建立内瘘又伴有CVC的增加。时机需权衡利弊！