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Vascular access surgery managed by renal physicians: the choice of native arteriovenous fistulas for hemodialysis.

BACKGROUND
After decades of success in dialysis research and treatment, prompt availability of a well-functioning vascular access for dialysis remains a disturbing problem. On the basis of a single-center experience in which nephrologists are responsible for access surgery, we sought to identify predictors of catheter use at the start of hemodialysis (HD) therapy and risk factors affecting first permanent access survival.


METHODS
Demographics, comorbid conditions, predialysis follow-up, and access-related procedures of the 197 consecutive patients beginning extracorporeal treatment between 1995 and 2001 were prospectively entered into our database.


RESULTS
Despite the high prevalence of comorbidities (diabetes, 22%; cardiovascular disease, 50%; neoplasm, 15%), all subjects received a native fistula as a first permanent access, but almost 60% initiated HD therapy using a catheter. The latter showed more comorbidities and were referred later. According to the Kaplan-Meier method, median primary and secondary survivals of the first fistula were 38.1 months and more than 70 months, respectively. The Cox model indicated that diabetes and previous catheter use were independently associated with 85% and 63% greater relative risks for first failure, but only diabetes led to a greater risk for final failure (relative risk, 2.38; P = 0.05).


CONCLUSION
Both the absence of predialysis care and presence of comorbidity influence access type at HD therapy initiation and fistula survival. Earlier intervention strategies can increase the use and durability of a native fistula for HD. Direct involvement of nephrologists in the management of access surgery can be helpful in this respect.