TY - JOUR
T1 - Relationships Between Clinical Processes and Arteriovenous Fistula Cannulation and Maturation
T2 - A Multicenter Prospective Cohort Study
AU - Allon, Michael
AU - Imrey, Peter B.
AU - Cheung, Alfred K.
AU - Radeva, Milena
AU - Alpers, Charles E.
AU - Beck, Gerald J.
AU - Dember, Laura M.
AU - Farber, Alik
AU - Greene, Tom
AU - Himmelfarb, Jonathan
AU - Huber, Thomas S.
AU - Kaufman, James S.
AU - Kusek, John W.
AU - Roy-Chaudhury, Prabir
AU - Robbin, Michelle L.
AU - Vazquez, Miguel A.
AU - Feldman, Harold I.
N1 - Publisher Copyright:
© 2017 National Kidney Foundation, Inc.
PY - 2018/5/1
Y1 - 2018/5/1
N2 - Background: Half of surgically created arteriovenous fistulas (AVFs) require additional intervention to effectively support hemodialysis. Postoperative care and complications may affect clinical maturation. Study Design: Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study. Setting & Participants: 491 patients with single-stage AVFs who had neither thrombosis nor AVF intervention before a 6-week postoperative ultrasonographic examination and who required maintenance hemodialysis. Predictors: Postoperative care processes and complications. Outcomes: Attempted cannulation, successful cannulation, and unassisted and overall clinical maturation as defined by the HFM Study criteria. Results: AVF cannulation was attempted in 443 of 491 (90.2%) participants and was eventually successful in 430 of these 443 (97.1%) participants. 263 of these 430 (61.2%) reached unassisted and 118 (27.4%) reached assisted AVF maturation (overall maturation, 381/430 [88.6%]). Attempted cannulation was less likely in patients of surgeons with policies for routine 2-week versus later-than-2-week first postoperative visits (OR, 0.21; 95% CI, 0.06-0.70), routine second postoperative follow-up visits (OR, 0.39; 95% CI, 0.15-0.97), and a routine clinical postoperative ultrasound (OR, 0.28; 95% CI, 0.14-0.55). Attempted cannulation was also less likely among patients undergoing procedures to assist maturation (OR, 0.51; 95% CI, 0.27-0.98). Unassisted maturation was more likely for patients treated in facilities with access coordinators (OR, 1.91; 95% CI, 1.17-3.12), but less likely after precannulation nonstudy ultrasounds (OR per ultrasound, 0.42 [95% CI, 0.26-0.68]) and initial unsuccessful cannulation attempts (OR per each additional attempt, 0.90 [95% CI, 0.83-0.98]). Overall maturation was less likely with infiltration before successful cannulation (OR, 0.44; 95% CI, 0.22-0.89). Among participants receiving maintenance hemodialysis before AVF surgery, unassisted and overall maturation were less likely with longer intervals from surgery to initial cannulation (ORs for each additional month of 0.81 [95% CI, 0.76-0.88] and 0.93 [95% CI, 0.89-0.98], respectively) and from initial to successful cannulation (ORs for each additional week of 0.87 [95% CI, 0.81-0.94] and 0.88 [95% CI, 0.83-0.94], respectively). Limitations: Surgeons’ management policies were assessed only by questionnaire at study onset. Most participants received upper-arm AVFs, planned 2-stage AVFs were excluded, and maturation time windows were imposed. Some care processes may have been missed and the observational design limits causal attribution. Conclusions: Multiple processes of care and complications are associated with AVF maturation outcomes.
AB - Background: Half of surgically created arteriovenous fistulas (AVFs) require additional intervention to effectively support hemodialysis. Postoperative care and complications may affect clinical maturation. Study Design: Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study. Setting & Participants: 491 patients with single-stage AVFs who had neither thrombosis nor AVF intervention before a 6-week postoperative ultrasonographic examination and who required maintenance hemodialysis. Predictors: Postoperative care processes and complications. Outcomes: Attempted cannulation, successful cannulation, and unassisted and overall clinical maturation as defined by the HFM Study criteria. Results: AVF cannulation was attempted in 443 of 491 (90.2%) participants and was eventually successful in 430 of these 443 (97.1%) participants. 263 of these 430 (61.2%) reached unassisted and 118 (27.4%) reached assisted AVF maturation (overall maturation, 381/430 [88.6%]). Attempted cannulation was less likely in patients of surgeons with policies for routine 2-week versus later-than-2-week first postoperative visits (OR, 0.21; 95% CI, 0.06-0.70), routine second postoperative follow-up visits (OR, 0.39; 95% CI, 0.15-0.97), and a routine clinical postoperative ultrasound (OR, 0.28; 95% CI, 0.14-0.55). Attempted cannulation was also less likely among patients undergoing procedures to assist maturation (OR, 0.51; 95% CI, 0.27-0.98). Unassisted maturation was more likely for patients treated in facilities with access coordinators (OR, 1.91; 95% CI, 1.17-3.12), but less likely after precannulation nonstudy ultrasounds (OR per ultrasound, 0.42 [95% CI, 0.26-0.68]) and initial unsuccessful cannulation attempts (OR per each additional attempt, 0.90 [95% CI, 0.83-0.98]). Overall maturation was less likely with infiltration before successful cannulation (OR, 0.44; 95% CI, 0.22-0.89). Among participants receiving maintenance hemodialysis before AVF surgery, unassisted and overall maturation were less likely with longer intervals from surgery to initial cannulation (ORs for each additional month of 0.81 [95% CI, 0.76-0.88] and 0.93 [95% CI, 0.89-0.98], respectively) and from initial to successful cannulation (ORs for each additional week of 0.87 [95% CI, 0.81-0.94] and 0.88 [95% CI, 0.83-0.94], respectively). Limitations: Surgeons’ management policies were assessed only by questionnaire at study onset. Most participants received upper-arm AVFs, planned 2-stage AVFs were excluded, and maturation time windows were imposed. Some care processes may have been missed and the observational design limits causal attribution. Conclusions: Multiple processes of care and complications are associated with AVF maturation outcomes.
KW - Vascular access
KW - arteriovenous access
KW - arteriovenous fistula (AVF)
KW - cannulation
KW - end-stage renal disease
KW - fistula maturation
KW - hemodialysis
KW - patency
KW - process-of-care
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U2 - 10.1053/j.ajkd.2017.10.027
DO - 10.1053/j.ajkd.2017.10.027
M3 - Article
C2 - 29398178
AN - SCOPUS:85041584455
SN - 0272-6386
VL - 71
SP - 677
EP - 689
JO - American Journal of Kidney Diseases
JF - American Journal of Kidney Diseases
IS - 5
ER -