title: Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study.
abstract: BACKGROUND
  An arteriovenous (A-V) fistula is the optimal vascular access for hemodialysis. The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) recommends that fistulae should mature for at least one month before cannulation, but this recommendation is not evidence-based. If fistulae are created prior to ESRD and cannulation is possible earlier without compromising fistula survival, the need for temporary catheters would be reduced.
  
  
  METHODS
  Prospective observational data were analyzed for a random sample (N = 3674) of incident patients at the time of initiating hemodialysis, hemofiltration or hemodiafiltration in 309 facilities in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States, taking part in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
  
  
  RESULTS
  Although the proportion of patients who had pre-dialysis care by a nephrologist differed little between countries, there were large variations in the proportion of patients who commenced hemodialysis via an A-V fistula, A-V graft or central venous catheter. The usual time interval between referral and creation of A-V fistulae also differed greatly between countries. For new hemodialysis (HD) patients initiating HD with an A-V fistula (N = 894) the following results were observed: (1). median time to first cannulation varied greatly between countries: Japan and Italy (25 and 27 days), Germany (42 days), Spain and France (80 and 86 days), UK and US (96 and 98 days). (2). No association was found between cannulation <or=28 days versus>28 days for patient characteristics of age, gender, and fifteen different classes of patient co-morbid factors. (3). Risk of A-V fistula failure was increased for incident patients who had a prior temporary access [relative risk (RR) = 1.81, P = 0.01] or who were female (RR = 1.52, P = 0.02). (4). Cannulation <or=14 days after creation was associated with a 2.1-fold increased risk of subsequent fistula failure (P = 0.006) compared to fistulae cannulated>14 days. (5) No significant difference in A-V fistula failure was seen for fistulae cannulated in 15 to 28 days compared with 43 to 84 days.
  
  
  CONCLUSIONS
  Significant differences in clinical practice currently exist between countries regarding the creation of A-V fistulae prior to starting hemodialysis and the timing of initial cannulation. Cannulation within 14 days of creation is associated with reduced long-term fistula survival. Fistulae ideally should be left to mature for at least 14 days before first cannulation.
authors.affiliation: Department of Renal Medicine, Birmingham Heartlands Hospital, Birmingham, United Kingdom.
authors.forename: Hugh C
authors.initials: HC
authors.lastname: Rayner
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Pisoni
authors.forename: Brenda W
authors.initials: BW
authors.lastname: Gillespie
authors.forename: David A
authors.initials: DA
authors.lastname: Goodkin
authors.forename: Takashi
authors.initials: T
authors.lastname: Akiba
authors.forename: Tadao
authors.initials: T
authors.lastname: Akizawa
authors.forename: Akira
authors.initials: A
authors.lastname: Saito
authors.forename: Eric W
authors.initials: EW
authors.lastname: Young
authors.forename: Friedrich K
authors.initials: FK
authors.lastname: Port
mesh_terms: D000293:Adolescent; D000328:Adult; D000714:Anastomosis, Surgical; D002404:Catheterization; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D011897:Random Allocation; D006435:Renal Dialysis; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome