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Does Diabetes and Immunosuppressant Therapy play a role in Arteriovenous Fistula Non-Maturation?
Eddie Blay, Jr., BA, Aamna Ali, BA, Syamal D. Bhattacharya, MD, Shawn Gage, PA, Luigi Pascarella, MD, Jeffrey H. Lawson, MD,PhD.
Duke University Medical Center, Durham, NC, USA.
OBJECTIVE: Arteriovenous fistulas (AVFs) are the hemodialysis access of choice for about 350,000 adult Americans with end-stage renal disease. Unfortunately, AVFs often do not adequately mature rendering them non-functional. The literature does not support a clear consensus regarding absolute contraindications or risk factors for AVF maturation. Based on our experience we hypothesize that both diabetes and immunosuppression both negatively influence AVF maturation.
METHODS: We reviewed 205 consecutive patients who received either radiocephalic or brachiocephalic AVFs between January 2006 and August 2011. 187 patients underwent vein mapping preoperatively using Doppler ultrasound. Postoperatively, all patients underwent repeat vein mapping at a median period of 13 weeks. We compared the pre-and post-operative vein diameters for absolute and percent changes for patients in the following categories: a) Patients on immunosuppressants (n=23) versus without (n=182). b) Diabetics (n=135) versus Non-diabetics (n=70).
RESULTS: Of the 187 patients who underwent both pre- and post-operative vein mapping, the mean change in vein diameter was 2.1mm.Patients on immunosuppressants had a mean growth of 1.7mm versus 2.2mm in those without (p=0.41). Diabetic patients had a mean growth of 1.8mm versus 2.8mm in patients without diabetes (p=0.03).
CONCLUSIONS: Although there are some changes in diameter between all groups examined, there was a statistically significant difference between diabetic patients versus normoglycemic patients. Our sample size is limited for patients on immunosuppressant therapy, but our clinical observations were not confirmed statistically as there was no difference between the two groups. There are likely many biologically factors which impede maturation and remodeling of AVFs in patients on immunosuppressant therapy and diabetes. With the tremendous system wide costs associated with hemodialysis access and end stage dialysis, critical investigation into the biological underpinnings of AVF maturation would improve our understanding of patients at risk for AVF maturation failure.
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