Renal function, uraemia and early arteriovenous fistula failure.
BACKGROUND
Guidance varies regarding the optimal timing of arteriovenous fistula (AVF) creation. The aim of this study was to evaluate the association between uraemia, haemodialysis and early AVF failure.


METHODS
Immunoblotting and cell proliferation assays were performed on vascular smooth muscle cells (VSM) cells isolated from long saphenous vein samples to evaluate the cells' ability to proliferate when stimulated with uraemic (post-dialysis) and hyperuraemic (pre-dialysis) serum. Clinical data was collected prospectively for 569 consecutive radiocephalic (RCF) and brachiocephalic (BCF) fistulae. The primary outcome was AVF failure at 6 weeks. Dialysis status (haemodialysis (HD); pre-dialysis (Pre-D)), eGFR and serum urea were evaluated to determine if they affected early AVF failure.


RESULTS
Human VSM cells demonstrated increased capacity to proliferate when stimulated with hyperuraemic serum. There was no significant difference in early failure rate of either RCF or BCF depending on dialysis status (pre-D RCF 31.4% (n=188); pre-D BCF 22.4% (n=165); HD RCF 29.3% (n=99); HD BCF 25.9% (n=116); p=0.34). There was no difference in mean eGFR between those patients with early AVF failure and those without (11.2+/-0.2 ml/min/1.73 m2 vs. 11.6+/-0.4 ml/min/1.73 m2; p=0.47). Uraemia was associated with early AVF failure (serum urea: 35.0+/-0.7 mg/dl vs. 26.6+/-0.3 mg/dl (p<0.001)).


CONCLUSIONS
We present the first in vivo evidence of an association between adverse early AVF outcomes and uraemia. This is supported mechanistically by in vitro work demonstrating a pro-mitogenic effect of hyperuraemic serum. We hypothesise that uraemia-driven upregulation of VSM cell proliferation at the site of surgical insult in contributes to higher early AVF failure rates.
Department of Renal Surgery, Western Infirmary, Dumbarton Road, G11 6NY Glasgow, UK. EmmaAitken@nhs.net.
Emma
E
Aitken
Andrew
A
Jackson
Chia
C
Kong
Paul
P
Coats
David
D
Kingsmore
D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D015153:Blotting, Western; D001916:Brachial Artery; D002455:Cell Division / Q000187:drug effects; D002478:Cells, Cultured; D003470:Culture Media / Q000494:pharmacology; D004868:Equipment Failure; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D032389:Myocytes, Smooth Muscle / Q000187:drug effects / Q000473:pathology*; D011446:Prospective Studies; D017534:Radial Artery; D006435:Renal Dialysis; D012189:Retrospective Studies; D044967:Serum; D014511:Uremia / Q000097:blood / Q000503:physiopathology / Q000628:therapy*; D014654:Vascular Patency
D003470:Culture Media