Author Interview: “Evolution and Clinical Course of First (EVER) Fistulas and Grafts”
Eduardo Lacson, Jr., MD, MPH, FACP, FASN, Vice President Clinical Science, Epidemiology, and Research, Fresenius Medical Care North America
1. What was your inspiration or motivation for the article?
Reports from individual dialysis programs indicate a variation in fistula and graft outcomes — both in terms of being suitable/functional for dialysis after surgical placement and in subsequent course leading to failure and abandonment. In a large clinical trial from Dember, et al (JAMA, 2008), fistula maturation rates were reported between 50 and 60 percent, depending on the suitability criteria applied. To further confuse the issue, results are often presented for any newly constructed arteriovenous vascular accesses, combining results from patients with their first surgical access and those who have had multiple accesses during the course of dialysis. The development and functionality of the new access may be affected by prior surgery for fistula or grafts. Therefore, the overall maturation and failure rates for newly placed grafts and fistulas are not clearly established in the literature. We sought to fill this gap in knowledge by examining our cohort of patients new to dialysis, with no known prior arteriovenous access. These patients were treated within their first 15 days of first (ever) dialysis using a central venous catheter, and eventually had a new graft or fistula placed during their first year.
2. What are the main findings of your study?
- Out of 6,364 newly placed fistulas, only 3,376 (59 percent), became mature enough to be used with the catheter removed. Once usable, 666 (18 percent) of them failed within the first year.
- Out of 1,916 newly placed grafts, only 1,364 (71 percent), became mature enough to be used with the catheter removed. Once usable, 357 (26 percent) of them failed within the first year.
3. Were any of the findings unexpected?
There was a high rate of failure to mature in both fistulas and grafts, with a resulting inability to get rid of the hemodialysis catheter.
4. What should clinicians and patients take away from this study?
More study is needed on how to improve the maturation rate, or simply stated, the proportion of fistulas and grafts that lead to effective use and removal of the catheter. Potential issues that need to be addressed include surgical quality of fistulas and graft placement, factors that can optimize maturation, and care of the newly placed fistula so as to avoid damaging it during the first few attempts at cannulation for dialysis.