Klaus Konner

Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension

BACKGROUND Access-related problems are one of the major causes of morbidity in elderly patients with chronic kidney disease. The aim of this study was to assess potential risks and benefits in elderly patients comparing forearm arteriovenous fistula (AVF) and perforating vein AVF below the elbow for primary vascular access. METHODS A retrospective comparison of elderly patients (65.7 ± 9.3 years, 70.4% male patients, 36.2% late referral) undergoing primary vascular access surgery using forearm AVF (n = 50) and perforating vein AVF (n = 55) was performed over a 2-year period, including a multivariate analysis of potential risk factors and benefits of primary patency (PP = intervention-free access survival) and secondary patency (SP = access survival until abandonment). RESULTS Patency rates after 24 months were significantly higher in patients with perforating vein AVF (PP + SP: 78.2%) compared to forearm AVF (PP: 62%, SP: 56%, P = 0.04). Presence of diabetes mellitus in patients with forearm AVF was associated with a decreased PP [odds ratio (OR): 3.6, 95% confidence interval (CI): 0.9-13.8] and SP (OR: 4.8, 95% CI: 1.3-17.9), and arterial hypertension was associated with a lower PP (OR: 6.7, 95% CI: 0.8-53.9), whereas the presence of hyperparathyroidism was associated with higher PP and SP (OR: 0.2, 95% CI: 0.1-0.7). In contrast, PP and SP in patients with perforating vein AVF were not influenced by comorbidities. CONCLUSIONS Perforating vein AVF is superior to forearm AVF in elderly patients with diabetes and arterial hypertension due to the proximal fistula location, probably caused by an improved artery distensibility during fistula maturation.

Placing a primary arteriovenous fistula that works—more or less known aspects, new ideas

Despite the pre-operative availability of well-defined criteria to create a primary arteriovenous fistula (AVF) a high early failure/missing maturation is complained worldwide. Based on new results from basic research using numerical techniques, the authors try to guide attention to a widely neglected field in published data: the unremarkable, small, but essential surgical details in creating a successful AVF. The aim is to describe their significance and to give them a place in a cross-border context.

The haemodialysis arteriovenous graft: is a new era coming?

The worldwide increase in the incidence and prevalence of haemodialysis (HD) patients is determining the growing demand of vascular access (VA) placement [1]. It is also wellknown that the VA issue imposes a major financial burden on healthcare systems and can be associated with increased morbidity and mortality [2]. VA dysfunction is a major cause of morbidity and mortality in HD patients [3]. Between the Fistula First Breakthrough Initiative [4] and strategies for decreasing the use of HD catheters, ‘fistula first/ catheter last’ [5], there is a renewed research effort aimed at improving the poor outcomes of arteriovenous graft (AVG). In fact, the major disadvantages of synthetic AVGs include the development of graft stenosis, a 5-fold increase in infection risk, a poorer long-term patency, higher levels of complications and more interventions than autogenous arteriovenous fistulas (AVFs) [6]. At the present time, for nephrologists, AVG means reduced primary patency rates, hospitalizations, use of central vein catheters, invasive surgical or less invasive interventional procedures, increased morbidity and mortality beyond the aspect of increase in costs. In this issue of Nephrology Dialysis Transplantation, Paulson et al. [7] provide evidence that an easily clinically applicable therapy, such as the periadventitial delivery of sirolimus, may improve HD graft patency and prolong its functional life.