Superiority of autogenous arteriovenous hemodialysis access: maintenance of function with fewer secondary interventions

Abstract

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF K/DOQI) guidelines have advocated autogenous arteriovenous fistulae as a primary procedure for hemodialysis access. This study compared the clinical outcomes between autogenous and prosthetic arteriovenous hemodialysis accesses, determining factors contributing to primary and secondary patency and function. Associated risk factors and number of interventions required to maintain secondary patency in each cohort were also assessed. A vascular database review of consecutive hemodialysis access procedures performed during a 36-month period (January 1999 to December 2001) at an academic institution was conducted. Life-table and log-rank analyses were used to analyze patency rates. Univariate and multivariate analysis was used to analyze risk factor influence on patency and function. A total of 231 upper extremity arteriovenous access procedures were performed in 209 patients during this period. One hundred autogenous accesses were created in 100 patients, 68 being forearm Brescia-Cimino arteriovenous fistulae. A total of 131 prosthetic accesses (ePTFE) grafts were also placed during this period in 109 patients. The demographic profiles of both cohorts were similar. Primary patency at 1 and 2 years was 56% (CI 45-76%) and 39% (CI 28-50%), respectively, in the autogenous group, and 36% (CI 26-45%) and 9% (CI 3-14%), respectively, in the prosthetic group. Differences in secondary patency at 1 year and 2 years were not significant (64% [CI 54-74%] and 53% [CI 42-65%] in the autogenous group vs. 65% [CI 55-73%] and 46% [CI 36-55%] in the prosthetic group). Secondary interventions were required in 87% of the prosthetic cohort (average 0.92 procedures/patient/year) and 57% of the autogenous cohort (average 0.53 procedures/patient/year). Multivariate analysis of associated risk factors demonstrated no significant effects on either primary or secondary patency in both groups. Autogenous accesses have superior primary patency and maintain equal secondary patency with significantly fewer interventions. These data strongly support the NKF K/DOQI guidelines recommending creation of autogenous access whenever possible. These outcomes can provide significant health-care cost benefits when using an algorithm favoring primary creation of autogenous access for hemodialysis.