The Evolution And Progression Of Autogenous Fistulae Over A 20 Year Period Since NKF-KDOQI
stephen L. hill, md.
carilion medical system, roanoke, VA, USA.
OBJECTIVES: The Fistula First and National Kidney Foundation - Kidney Dialysis Outcomes Quality Initiative in the 1990’s had a major effect on dialysis access surgery. It caused an increase in autogenous fistulae construction, but had the unintended consequence of increased use and time of tunneled dialysis catheters. METHODS: I have reviewed the results of my dialysis access at a major medical center over 20 years to see the effect of the new recommendations and compared it to the types of surgery I performed in the preceding 15 years.RESULTS: There were a total of 2,557 patients who had 3,575 procedures for dialysis access in the study period. Of this group, there were 844 autogenous dialysis accesses (82%) compared to 177 prosthetic grafts (18%). In the 15 years prior to 1998 the percentages were essentially reversed- there were 49 autogenous fistulae (17.4%) and 232 prosthetic grafts (82.5 %). In the years prior to DOKI,- Cimino and brachiocephalic fistulae were the only autogenous accesses constructed. In the last 20 years the dialysis population has grown significantly, requiring more access procedures, which in turn required an increase in the variety of autogenous fistula to avoid use of a prosthetic graft. The new additions also increased patency. The patency rates were Cimino fistula (63.29%), Brachial cephalic (75.19%), Transposition of the midforearm cephalic vein (56.71%), Brachial Vein transposition (72.60%), and Basilic vein transposition (83.78%). The patency rate for Prosthetic grafts for dialysis access was 67.79% in this study. The autogenous fistula required more attempts and revisions (206) than prosthetic grafts (85). Furthermore, the autogenous fistulae required a long maturation period with no assurance of success thus necessitating much longer periods of dialysis catheter use. Prosthetic grafts require minimal, if any, maturation time. Prior to the current era, there were 168 catheter placements in 315 patients and now the number has increased to 1,464 catheter placements in 1,021 patients, more than double the number from the previous era. CONCLUSIONS:
The conversion to the construction of autogenous fistula over the last 20 years required more planning and meticulous surgical technique but in the end has improved patency of dialysis access at the expense of more surgical procedures and prolonged use of dialysis catheters.
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