People who receive chronic hemodialysis depend on a functional vascular access to allow use of this predominant form of treatment for end stage kidney failure. Vascular access practice varies greatly internationally, with better outcomes typically seen when using an arteriovenous fistula (AVF). Generally, placing the AVF in the lower arm is preferred as there is less risk of exhausting available sites for future AVFs. Given the large international variation in vascular access practice and outcomes, researchers sought to further understand international differences by examining data from the Dialysis Outcomes and Practice Patterns Study (DOPPS).
Investigators compared three regions: the United States, Europe/Australia/New Zealand (EUR/ANZ), and Japan. They found large international differences in AVF location, predictors of AVF location, successful use of AVFs, and time to first use of AVFs.
Of note, between 1996 and 2015, at least 93 percent of AVFs in Japan were created in the lower arm as opposed to the upper arm. In EUR/ANZ, this number ranged from 65 to 77 percent, and in the US it declined from 70 percent to 32 percent.
“The large shift that we see in the US from lower to upper arm AVFs raises some serious concerns about the long-term health implications for some patients,” said lead author Dr. Ronald L. Pisoni.
This shift may be partially explained by efforts and pressures to achieve higher AVF use rates in response to the Fistula First Initiative, and it suggests a selection bias in the US to succeed with larger upper arm vessels in the first attempt. In Japan and EUR/ANZ practitioners may delay using upper arm vessels until after failed lower arm fistula(e).
This and other large international differences found in this paper raise important questions regarding what is best practice and how it is best achieved to optimize vascular access outcomes.