title: Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients.
abstract: BACKGROUND
  Most guidelines recommend the creation of arteriovenous fistula (AVF) in patients with chronic kidney disease (CKD) stage 4. However, an increasing number of studies suggest that early AVF creation leads to high rates of AVF failure and death before dialysis commencement. Only the Japanese guideline recommends AVF creation at CKD stage 5; however, no data are available regarding access-related outcomes at this stage.
  
  
  METHODS
  This was a multicenter cohort study involving Japanese CKD stage 5 patients who underwent preemptive AVF creation from 2009 to 2013. The primary outcome was unnecessary AVF creation, defined as death before requiring dialysis or AVF failure before dialysis commencement. The secondary outcome was dialysis commencement. The associations with candidate predictors and the outcomes were examined.
  
  
  RESULTS
  A total of 303 patients were registered. Four cases of death before dialysis and 13 cases of AVF failure before dialysis commencement were observed. A total of 283 patients who advanced to dialysis were found to have functional AVFs. The cumulative incidences of unnecessary AVF creation and dialysis commencement at 1 year were 4.8 and 89.3%, respectively. Competing risk regression analyses showed that age ≥75 years (subhazard ratio [SHR] 3.12, 95% CI 1.20-8.09) and female gender (SHR 3.31, 95% CI 1.20-9.09) were associated with unnecessary AVF creation.
  
  
  CONCLUSIONS
  A low incidence of unnecessary AVF creation was revealed among Japanese patients who received AVF at CKD stage 5. These results may help clarify the natural history of unnecessary AVF creation for other countries reformatting their guidelines regarding late vascular access creation.
authors.affiliation: Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Masahito
authors.initials: M
authors.lastname: Miyamoto
authors.forename: Noriaki
authors.initials: N
authors.lastname: Kurita
authors.forename: Kotaro
authors.initials: K
authors.lastname: Suemitsu
authors.forename: Masaaki
authors.initials: M
authors.lastname: Murakami
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000592:standards; D005260:Female; D006801:Humans; D007564:Japan; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D006435:Renal Dialysis / Q000379:methods* / Q000592:standards; D012189:Retrospective Studies; D018570:Risk Assessment; D017211:Treatment Failure; D016896:Treatment Outcome; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*