Hospital specific aspects predominantly determine primary failure of hemodialysis arteriovenous fistulas

Abstract

Background: Primary failure of the arteriovenous fistula (AVF) is a major problem affecting native hemodialysis access use. A multicenter guideline implementation program, Care Improvement by Multidisciplinary approach for Increase of Native vascular access Obtainment (CIMINO), was designed to identify modifiable and nonmodifiable factors involved in the early functionality of the AVF.

Methods: Physicians and dialysis staff in 11 centers in the Netherlands (N = 1092 prevalent vascular accesses) were strongly and repeatedly advised to adhere to current guidelines. It was advised to always perform a standard preoperative duplex examination and physicians were encouraged to attempt salvaging procedures for failing and failed fistulae. Specially appointed access nurses prospectively registered all created vascular accesses in an internet-linked database. Primary failure (PF) was defined as a complication of the AVF before the first successful cannulation for hemodialysis treatment. Modifiable and nonmodifiable factors were related to risk of primary failure using logistic regression models. We restricted the analyses to the first AVF of each patient that was placed during the observation period.

Results: Between May 2004 and May 2006, an AVF was created in 395 patients. Primary failure occurred in one third (131 cases). Factors related to an increased risk of primary failure were female gender (odds ratio (OR): 1.73, 95% confidence interval (CI): 1.01-2.94), renal replacement therapy prior to AVF placement (OR: 1.19 per year on RRT, CI: 1.05-1.34), diabetes mellitus (OR: 3.08, CI: 1.53-6.20), and AVF placement at the wrist (compared with elbow) (OR: 1.86, CI: 1.03-3.36). Primary failure rate among the participating centers varied from 8% to 50%. Compared to the two centers with the lowest primary failure rates, six centers had a significantly higher primary failure rate. Adjustment for risk factors and surgery-related factors did not materially change the center-related findings.

Conclusion: In conclusion, we have identified location of AVF placement as a modifiable factor influencing primary failure risk. More importantly, this study shows that the probability of primary failure is strongly related to the center of access creation, suggesting an important role for the vascular surgeon's skills and decisions.