Primary arteriovenous fistula failure in patients on maintenance hemodialysis: prevalence, risk factors, and impact on long-term outcomes

Objective: to assess the prevalence of primary arteriovenous fistula (AVF) failure in patients commencing chronic hemodialysis, to evaluate the relationship between primary failure and long-term outcomes, and to identify risk factors for its development. Materials and methods. This retrospective cohort study reports the outcomes of 1595 adult patients starting chronic hemodialysis treatment for the first time. Results. Primary failure was noted in 369 patients (23.1%), whereas in 1,226 patients (76.9%), the AVF matured normally and was accessible to puncture without additional interventions. Follow-up by a nephrologist, preoperative evaluation by a surgeon, and ultrasound were linked to a lower risk of primary failure: RR = 0.624 [95% CI 0.523; 0.746], p < 0.001; 0.648 [0.469; 0.894], p = 0.005; and 0.606 [0.471; 0.78], p < 0.001 (when ultrasound was performed by or in the presence of a surgeon 0.372 [0.24; 0.577], p < 0.001), respectively. The risk of primary failure increased if AVF was created in two weeks and one week before, and during the first and second weeks after hemodialysis initiation. In single-factor analysis, primary failure was linked to a higher risk of all-cause mortality (HR = 1.54 [1.20; 1.97], p < 0.001), but not after adjustment for age and comorbidity (HR = 1.11 [0.85; 1.44], p = 0.761). Primary failure was associated with poorer secondary patency (HR = 1.79 [1.28; 2.51] p < 0.001) and increased need for reconstructive interventions (IRR = 2.199 [1.985; 2.434], p < 0.001). Conclusion. Risk reduction factors for primary failure include follow-up by a nephrologist, preliminary examination by a surgeon, supplemented by ultrasound scan. Primary failure is not linked to decreased patient survival (after adjustment for comorbid background and age), but to decreased secondary patency of vascular access.