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Kamar F, Quinn RR, Oliver MJ, Viecelli AK, Hiremath S, MacRae J, Miller L, Blake P, Moist L, Garg AX, Lam NN, Kabani R, Clarke A, Liu P, Gillespie B, Ravani P. Outcomes of the First and Second Hemodialysis Fistula: A Cohort Study. Am J Kidney Dis 2018; 73:62-71. [PMID: 30122545 DOI: 10.1053/j.ajkd.2018.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 06/11/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Fistulas are the preferred form of hemodialysis access; however, many fistulas fail to mature into usable accesses after creation. Data for outcomes after placement of a second fistula are limited. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS People who initiated hemodialysis therapy in any of 5 Canadian dialysis programs (2004-2012) and had at least 1 hemodialysis fistula placed. PREDICTOR Second versus initial fistula; receipt of 2 versus 1 fistula; second versus first fistula in recipients of 2 fistulas. OUTCOMES Catheter-free fistula use during 1 year following initiation of hemodialysis therapy or following fistula creation, if created after hemodialysis therapy start; proportion of time with catheter-free use; time to catheter free use; time of functional patency. ANALYTICAL APPROACH Logistic regression; fractional regression. RESULTS Among the 1,091 study participants (mean age, 64±15 [SD] years; 63% men; 59% with diabetes), 901 received 1 and 190 received 2 fistulas. 38% of second fistulas versus 46% of first fistulas were used catheter free at least once. Average percentages of time that second and initial fistulas were used catheter free were 34% and 42%, respectively (OR, 0.72; 95% CI, 0.54-0.94). Compared with people who received 1 fistula, those who received 2 fistulas were less likely to achieve catheter-free use (26% vs 56%) and remain catheter free (23% vs 49% of time; OR, 0.30, 95% CI, 0.24-0.39). Among people who received 2 fistulas, the proportion of time that the second fistula was used catheter free was 11% higher with each 10% greater proportion of time that the first fistula was used catheter free (95% CI, 1%-22%). Model discrimination was modest (C index, 0.69). LIMITATIONS Unknown criteria for patient selection for 1 or 2 fistulas; unknown reasons for prolonged catheter use. CONCLUSIONS Outcomes of a second fistula may be inferior to outcomes of the initial fistula. First and second fistula outcomes are weakly correlated and difficult to predict based on clinical characteristics.
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Affiliation(s)
- Fareed Kamar
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert R Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthew J Oliver
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea K Viecelli
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, The University of Ottawa, Ottawa, ON, Canada
| | - Jennifer MacRae
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lisa Miller
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Blake
- Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada; Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Louise Moist
- Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada; Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Amit X Garg
- Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada; Division of Nephrology, Department of Medicine, Western University, London, ON, Canada; Institute for Clinical Evaluative Sciences, ON, Canada
| | - Ngan N Lam
- University of Alberta, Edmonton, AB, Canada
| | - Rameez Kabani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alix Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ping Liu
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Brenda Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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