Predictors of adequacy of arteriovenous fistulas in hemodialysis patients

Background. Dialysis access procedures and complications represent a major cause of morbidity, hospitalization, and cost for chronic dialysis patients. To improve the outcomes of hemodialysis access procedures, recent clinical guidelines have encouraged attempts to place an arteriovenous (A-V) fistula, rather than an A-V graft, whenever possible in hemodialysis patients. There is little information, however, about the success rate of following such an aggressive strategy in the prevalent dialysis population. Methods. We evaluated the adequacy of all A-V fistulas placed in University of Alabama at Birmingham dialysis patients during a two-year period. A fistula was considered adequate if it supported a blood flow of greater than or equal to 350 ml/min on at least six dialysis sessions in one month. Fistula adequacy was correlated with clinical and demographic factors. Results. The adequacy could be determined for 101 fistulas; only 47 fistulas (46.5%) developed sufficiently to be used for dialysis. The adequacy rate was lower in older (age greater than or equal to 65) versus younger (age < 65) patients (30.0 vs. 53.5%, P = 0.03). It was also marginally lower in diabetics versus nondiabetics (35.0 vs. 54.1%, P = 0.061) and in overweight (BMI greater than or equal to 27 kg/m(2)) versus nonoverweight patients (34.5 vs. 55.2%, P = 0.07). The adequacy rate was not affected by patient race. smoking status, surgeon. serum albumin, or serum parathyroid hormone. The adequacy rate was substantially lower for forearm versus upper arm fistulas (34.0 vs. 58.9%, P = 0.012). The adequacy of forearm fistulas was particularly poor in women (7%), patients age 65 or older (12%), and diabetics (21%). In contrast, upper arm fistulas were adequate in 56% of women, 54% of older patients, and 48% of diabetics. Conclusions. An aggressive approach to the placement of fistulas in dialysis patients results in a less than 50% early adequacy rate, which is considerably lower than that reported in the past. Moreover, the success rate of fistulas is even lower for certain patient subsets. To achieve an optimal outcome with A-V fistulas, we recommend that they be constructed preferentially in the upper arm in female, diabetic, and older hemodialysis patients.