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The Paradox Continues: Improved Outcomes in Radiocephalic Fistulas in Patients with Elevated Body Mass Index (BMI)
Meg Reeves, BS, Michael F. Amendola, MD, Marc Posner, John Pfeifer, Ronald Davis.
VA Medical Center/VCU Health System, Richmond, VA, USA.

The obesity paradox has been well described in the nephrology literature leading to improved outcomes in patients with elevated BMI.1 Elevated BMI has been refuted as having a larger a causative failure rate in arteriovenous fistulas.2 We set forth to examine the outcomes of patients with elevated BMI undergoing primary radiocephalic (RC) fistula placement.
We obtained Institutional Board Review approval to retrospectively query our Veterans Administration Hospital dialysis access database from January 1, 2003 to December 31, 2011 to identify all patients who had primary RC fistula placement. We followed outcomes until July 30 2017 for an additional 67 to 145 months after RC placement. Patients were stratified as having low BMI (< 30 kg/m2) or high BMI (≥ 30 kg/m2). Outcomes examined including successful cannulation, functional utilization time (successful needle cannulation and usage on dialysis), total duration (time from access creation to occlusion or revision), rates of access thrombosis once cannulated and endovascular interventions per access.
Total number 174 RC were performed in 168 male patients during the study period.

High BMI
p value*
Average BMI kg/m2 (mean +/- SD)24.7 ±3.234.9 ± 4.3<0.0001
Alive at Study End35/117 pts (30%)25/57 pts (44%)0.09*
Age (mean years +/- SD)73.7 ± 11.167.1 ± 9.80.0002
Diabetes51/117 pts (43.6%)43/57 pts (75.5%)<0.0001*
Successful Cannulation48/117 pts (41%)31/57 pts (54%)0.10*
Functional Patency Days (mean +/- SD)762.8 ± 925.41308.3 ± 1202.30.04
Endovascular Interventions per Access (mean +/- SD)0.76 +/- 2.10.91 +/- 1.60.25

*Fisher’s Exact Test Wilcoxon Rank Sum
RC is considered a first line operative procedure for those receiving hemodialysis. Regardless of BMI, patients had similar cannulation rates and endovascular interventions. Interestingly, patients with higher BMI were statistically younger with higher rates of diabetes and an almost double functional patency. These data continue to add detail to the obesity paradox in patients with RC fistulas receiving dialysis.
1 Schmidt, Darren S.; Salahudeen, Abdulla K. Cardiovascular and Survival Paradoxes in Dialysis Patients: Obesity-Survival Paradox-Still a Controversy? Seminars in Dialysis. 2007; 20(6): 486-92.
2 Vassalotti JA, Falk A, Cohl ED, Uribarri J, Teodorescu V. Obese and non-obese hemodialysis patients have a similar prevalence of functioning arteriovenous fistula using pre-operative vein mapping. Clin Nephrol 2002;58:211-4.
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