Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates

Abstract

Importance: National initiatives have emphasized the use of autogenous arteriovenous fistulas (AVFs) for hemodialysis, but their purported benefits have been questioned.

Objective: To examine AVF usability, longer-term functional patency, and remedial procedures to facilitate maturation, manage complications, or maintain patency in the Hemodialysis Fistula Maturation (HFM) Study.

Design, setting, and participants: The HFM Study was a multicenter (n = 7) prospective National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases cohort study performed to identify factors associated with AVF maturation. A total of 602 participants were enrolled (dialysis, kidney failure: 380; predialysis, chronic kidney disease [CKD]: 222) with AVF maturation ascertained for 535 (kidney failure, 353; CKD, 182) participants.

Interventions: All clinical decisions regarding AVF management were deferred to the individual centers, but remedial interventions were discouraged within 6 weeks of creation.

Main outcomes and measures: In this case series analysis, the primary outcome was unassisted maturation. Functional patency, freedom from intervention, and participant survival were summarized using Kaplan-Meier analysis.

Results: Most participants evaluated (n = 535) were men (372 [69.5%]) and had diabetes (311 [58.1%]); mean (SD) age was 54.6 (13.6) years. Almost two-thirds of the AVFs created (342 of 535 [64%]) were in the upper arm. The AVF maturation rates for the kidney failure vs CKD participants were 29% vs 10% at 3 months, 67% vs 38% at 6 months, and 76% vs 58% at 12 months. Several participants with kidney failure (133 [37.7%]) and CKD (63 [34.6%]) underwent interventions to facilitate maturation or manage complications before maturation. The median time from access creation to maturation was 115 days (interquartile range [IQR], 86-171 days) but differed by initial indication (CKD, 170 days; IQR, 113-269 days; kidney failure, 105 days; IQR, 81-137 days). The functional patency for the AVFs that matured at 1 year was 87% (95% CI, 83.2%-90.2%) and at 2 years, 75% (95% CI, 69.7%-79.7%), and there was no significant difference for those receiving interventions before maturation. Almost half (188 [47.5%]) of the AVFs that matured had further intervention to maintain patency or treat complications.

Conclusions and relevance: The findings of this study suggest that AVF remains an accepted hemodialysis access option, although both its maturation and continued use require a moderate number of interventions to maintain patency and treat the associated complications.

Figure 1.. Flow Diagram of the Participants

A flow diagram of the participants enrolled in the study, as categorized by their initial dialysis status (kidney failure vs chronic kidney disease [CKD]), is shown for the autogenous arteriovenous fistula (AVFs) that were ascertained, the AVFs that matured, and the AVFs that were used for dialysis until abandonment. ^aDeath (n = 19), alternative dialysis modality (n = 3), lost to follow-up (n = 5). ^bDeath (n = 8), alternative dialysis modality (n = 6), lost to follow-up (n = 2), never started dialysis (n = 24). ^cMedian follow-up, 26 months (interquartile range, 17-37 months). ^dMedian follow-up, 28 months (interquartile range, 18-39 months).

Figure 2.. Cumulative Incidence of Maturation in Participants Shown by Their Initial Dialysis Status

A, The cumulative incidence of autogenous arteriovenous fistula (AVF) maturation is shown for participants with kidney failure (A) and chronic kidney disease (B) who were evaluated. B, The cumulative incidence of unassisted and assisted AVF maturation is shown for participants with kidney failure (C) and chronic kidney disease (D) who were evaluated.

Figure 3.. Functional Patency and Freedom From Intervention After Autogenous Arteriovenous Fistula (AVF) Maturation

A, The functional patency for participants whose AVF was successfully used for dialysis. The kidney failure and chronic kidney disease groups were combined, given the lack of significant difference between these groups (eFigure 2 in the Supplement). B, The freedom from intervention for the participants after successful AVF maturation. The shaded areas indicate 95% CIs.