Arteriovenous access placement and renal function decline

Arteriovenous fistula in predialysis chronic kidney disease patients and rate of decline of glomerular filtration rate

PURPOSE

To quantify the evidence for the role of arteriovenous fistula (AVF) in predialysis CKD patients for the rate of decline of glomerular filtration rate (GFR).

BACKGROUND

Pre-emptive placement of arteriovenous fistula (AVF) in late-stage chronic kidney disease (CKD) patients is being advocated by all the major guidelines. Recent studies have suggested that pre-emptive AVF has a beneficial effect on glomerular filtration rate (GFR) also.

METHODS

We conducted a literature search to retrieve all published studies related to the effect of AVF on the rate of decline of GFR using the electronic databases Google Scholar, PubMed, Central, Cochrane Library, clinialtrial.gov. Screening of studies and data extraction were done according to the PRISMA guidelines. We used the NIH assessment tool for the methodological quality assessment of the included studies. Extracted data from the six studies were pooled and analyzed.

RESULTS

Six studies involving 3871 patients reported the effect of AVF creation on the rate of decline of GFR in late CKD patients. Evidence for statistically significant decline of eGFR after AVF creation compared to prior status (SMD -1.57, 95% CI -3.08 to -0.07, p < 0.001) was observed.

CONCLUSION

Our meta-analysis observed preliminary evidence that the creation of AVF might have a potential added benefit in terms of estimated GFR improvement, though to a very small extent with a low level of certainty. More scientific data with high-quality studies are needed to substantiate this finding.

Arteriovenous Fistula Creation and Estimated Glomerular Filtration Rate Decline in Advanced CKD: A Matched Cohort Study

Background

Kidney failure is associated with a high burden of morbidity and mortality. Previous studies have raised the possibility that arteriovenous fistula (AVF) creation may attenuate eGFR decline. This study aimed to compare eGFR decline in predialysis patients with an AVF, matched to patients oriented toward peritoneal dialysis (PD).

Methods

Predialysis patients with an AVF and those oriented toward PD were retrospectively matched using a propensity score. Time zero was defined as the "AVF creation date" for the AVF group and the "date when eGFR was closest to the matched patient's eGFR at AVF creation" for the PD group. Crude and predicted eGFR decline in AVF and PD groups were compared before and after time zero using mixed-effect linear regressions.

Results

In total, 61 pairs were matched. Crude annual eGFR decline before AVF creation/time zero was -4.1 ml/min per m² per year in the AVF group versus -5.3 ml/min per m² per year in the PD group (P=0.75) and after time zero, -2.5 ml/min per m² per year in the AVF group versus -4.5 ml/min per m² per year in the PD group (P=0.02). The predicted annual decline decreased from -5.1 ml/min per m² per year in the AVF group before AVF creation to -2.8 ml/min per m² per year after (P<0.01), whereas there was no difference in the PD group (-5.5 versus -5.1 ml/min per m² per year respectively, P=0.41).

Conclusions

In this matched study, AVF creation was associated with a deceleration of kidney function decline compared with a control PD-oriented group. Prospective studies are needed to assess the potential mechanisms between vascular access creation and eGFR slope attenuation.