Arteriovenous Grafts Still Have a Place in Dialysis
Article Outline
To the Editor:
Wasse et al recently identified older age, female sex, black race, and cardiovascular co-morbidity as independent factors for delayed transition from a catheter to a permanent vascular access in hemodialysis patients.1 I applaud their research methodology and clinically relevant observations. However, I have some comments regarding the interpretation of their findings.
First, the authors claim that “blacks appear to be equally suited for AVF [arteriovenous fistula] creation based on known vascular anatomy.” This may not be the case. Our dialysis center found, using objective vascular mapping criteria, that blacks were less likely than whites to have suitable anatomy for AVF creation.2
Second, the authors postulate that smaller vein caliber may account in part for the lower AVF use in women. They propose that selection of adequately sized vessels by preoperative vascular mapping may correct this discrepancy. In fact, our center reported that despite routine mapping and comparable vessel size, fistulas still had a higher primary failure rate in women.3
Finally, recent studies have identified the same clinical factors (older age, female sex, black race, and cardiovascular co-morbidity) as being associated with a higher risk of primary fistula failure.3, 4 Certainly, as the authors point out, greater efforts at early fistula placement and interventions to promote maturation may be helpful. However, in our zeal to increase fistula use, we should also recognize that grafts may be a better access choice in a subset of patients at high risk for primary fistula failure. This would permit a faster transition to a permanent access rather than having prolonged catheter dependence due to immature fistulas.
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References
- . Predictors of delayed transition from central venous catheter use to permanent vascular access among ESRD patients. Am J Kidney Dis. 2007;49:276–283
- Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney Int. 2001;60:2013–2020
- . Gender differences in outcomes of arteriovenous fistulas in hemodialysis patients. Kidney Int. 2003;63:346–352
- . REDUCE FTM I (Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas). J Am Soc Nephrol. 2006;17:3204–3212
PII: S0272-6386(07)00733-0
doi:10.1053/j.ajkd.2007.03.023
© 2007 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved.
Refers to article:
- In Reply
- Predictors of Delayed Transition From Central Venous Catheter Use to Permanent Vascular Access Among ESRD Patients , 30 December 2006
