Analysis of Risk Factors for Early Access Failure of AVF in Patients on Hemodialysis 경희 대학교 의과대학 내과학교실 문수연, 박병조, 이향이, 정경환, 김정희, 이상호, 이태원, 임천규, 김명재

Background End-stage renal disease – Dialysis: HD (60.2%) > PD (17.5%) (Renal replacement therapy in Korea – Insan Memorial Dialysis Registry 2003) – AV fistula vs AV graft Early access failure of AVF(~ 30%) – Definition AVF never develops to the point used AVF fails within first 3 months of surgery (Semin Dial 2000, 13)

Risk factors of early access failure of AVF – Local risk factors Blood flow at AVF access site – < 700 mL/min – risk for early access failure (Nephrol Dial Transplant, 2004, 19) Diameter of artery and vein – < 1.6 mm – risk for early access failure (Eur J Endovasc Surg, 1996, 12) Doppler US – Systemic factors → risk factor ?

Aim To evaluate rate of early access failure of AVF To evaluate systemic risk factors for early access failure of AVF

Subjects and Methods Subjects – ~ – 111 patients with ESRD – Vascular access surgery and HD at KHMC Methods – Medical record by reviewing the charts – Statistic analysis

Methods Medical records – Causes of CKD, history of cardiovascular events – History of ipsilateral central venous catheter insertion – Laboratory finding at the time of surgery CBC/DC (hemoglobin, hematocrit) Calcium, phosphorus, parathyroid hormone, albumin – Medication history Aspirin, warfarin, clopidogrel, etc HMG-CoA reductase inhibitor ACEi or ARB

Results

Table 1. Type of vascular access of subjects AV fistulaAV graft Age (years)49.2 ± ± 13.3 Sex (M/F)60/6711/15 Total number12726 Primary choice1056 Early access failure (%)27 (21.3%)2 (7.7%)

Table 2. Baseline characteristics of patients with AVF Early access failureYes (n=27)No (n=100)p-value Age (years, mean ± SD)51.4 ± ± 15.0 ≤ > Sex (M/F)15/1245/ Causes of CKD DM11(40.7%)29(29.0%)0.24 Hypertension6(22.2%)29(29.0%)0.48 Glomerulonephritis5(18.5%)14(14.0%)0.56 Unknown3(11.1%)19(19.0%)0.34 Others2(7.4%)9(9.0%)0.79 History of cardiovascular events (%) 3(11.1%)2(2.0%)0.03 History of ipsilateral central catheter insertion (%) 9(33.3%)8(8.1%)0.001

Table 3. Medication history Early access failiureYes (n=27)No (n=100)p-value Anticoagulants & antiplatelet agents19(70.4%)38(39.6%)0.008 Aspirin1627 Warfarin30 Clopidogrel, persantin, ect1420 ACEi or ARB (%)7(25.9%)26(27.1%)0.91 HMG-CoA reductase inhibitor020.56

Table 4. Laboratory findings Early access failureYes (n=27)No (n=100)p-value Hemoglobin8.9 ± ± 1.6 ≤ 8 mg/dL > 8 mg/dL2035 Hematocrit26.3 ± ± 4.7 ≤ 25% > 25%1726 Calcium8.5 ± ± 1.2 ≤ 8.3 mg/dL > 8.3 mg/dL1143 Phosphorus5.8 ± ± 2.0 ≤ 5.7 mg/dL > 5.7 mg/dL1236 Ca X P ≤ > Albumin3.5 ± ± 0.7 ≤ 3 g/dL > 3 g/dL2362 PTH154.1 ± ± ≤ pg/mL > pg/mL624

Table 5. Multivariate anaylsis of risk factors for early access failure of AVF Odd ratio 95.0% C.I. for Odd ratio Sig. Lower Upper Age at the time of surgery Sex DM HTN History of cardiovascular event History of ipsilateral central catheter insertion Hemoglobin Albumin Ca X P Phosphorus

Summary Factors not related to early access failure of AVF – Sex, DM, HTN, PTH, Ca, P, Ca X P, ACEi or ARB, and HMG-CoA reductase inhibitor Factors related to early access failure of AVF – Univariate analysis Old age, history of ipsilateral central catheter insertion, history of cardiovascular events, and higher level of hemoglobin and hematocrit – Multivariate analysis History of ipsilateral central venous catheter insertion, and higher hemoglobin and albumin

Conclusion History of ipsilateral central venous catheter insertion, and higher hemoglobin and albumin – independent risk factor for early access failure of AVF