Nonfunctional arteriovenous access at hemodialysis initiation: Predictors and timing

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Nonfunctional arteriovenous access at hemodialysis initiation: Predictors and timing

Most recommendations agree that arteriovenous (AV) access is the best option for hemodialysis patients, and that timely AV access referral is one of the most effective measures for preventing catheter use at hemodialysis initiation, report French researchers (De Pinho A et al, Predictors of nonfunctional arteriovenous access at hemodialysis initiation and timing of accesscreation: A registry-based study.

PLoS One. 2017;12(7):e0181254). However, there still remains the challenge of defining the ideal timing for AV access placement, in particular for AV fistulae. On this point, guidelines so far have failed to come to an agreement. Currently, recommendations range from suggesting AV fistula creation at least 2 to 3 months before the start of hemodialysis, to at least 6 months or even 12 months. Another matter still under discussion is what determinants could help to predict nonfunctional AV access. In the present study, the authors used data from the French REIN Registry (which includes close to 30,000 patients) to investigate the timing of AV access placement and determinants of nonfunctional AV access at hemodialysis initiation.

The main results:

• Overall, 18 % patients had nonfunctional AV access at hemodialysis initiation, particularly women and those with comorbidities.
• In the group with a planned dialysis start, independent predictors of nonfunctional AV access were female gender, diabetes and a higher number (>3) of cardiovascular comorbidities (OR 1.43, 1.28 and 1.31, respectively).
• The odds of nonfunctional AV access decreased as time from creation to hemodialysis initiation increased up to 3 months in nondiabetic patients with < 2 cardiovascular comorbidities and 6 months in patients with diabetes or ≥ 2 such comorbidities.

In this cohort, a substantial proportion of patients had nonfunctional AV access at HD initiation. The most important determinant may be delayed AV access creation. The authors recommend adjusting the timing of AV access creation to each patient’s comorbidity profile to improve functional AV access rates at hemodialysis initiation.

Link to the study: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0181254