Larger studies needed to assess AVGs vs AVFs
Click Here to Manage Email Alerts
Researchers who compared arteriovenous grafts with arteriovenous fistulas in patients aged 65 years or older with end-stage kidney disease found scant evidence favoring one treatment over the other.
This led Todd Robinson, MD, of the section of nephrology at Wake Forest School of Medicine, and colleagues to conclude that a larger randomized clinical trial could prove useful.
“Overall, [the] results lend significant support to recent studies that have suggested that patient-specific factors, rather than the vascular access itself, explains at least two-thirds of the mortality benefit historically credited to AVFs,” the researchers wrote.
Annually, about 750,000 Americans receive hemodialysis for ESKD, with older adults accounting for half of this population, according to the researchers.
“In caring for these patients, timely placement of an arteriovenous vascular access (AVF or AVG) for [hemodialysis] HD is desirable to limit the long-term use of tunneled central venous catheters [CVC],” the researchers wrote. “Present clinical practice has followed a categorized order of preference for dialysis vascular access, with first, second, and last choice given to arteriovenous AVF, AVG, and CVC, respectively. Whether such a stereotypical approach to vascular access placement, fortified by current financial reimbursement models, benefits all hemodialysis patients is a point of growing contention.”
To fill the void created by few trials investigating this subject, the researchers assembled a group of older patients on maintenance HD via a CVC with no prior AV access. The patients obtained a referral for AV access placement by their nephrologists. Thirty-six eligible patients were randomized to either an AVG or AVF group. Ultimately, 13 patients underwent the AVG and 16 underwent the AVF surgeries. The mean age of the patients was 76.5 years. Success or failure of the surgeries was dependent upon its functionality for HD, the researchers wrote.
The results indicated no significant evidence to favor grafts or fistulas in older patients with ESKD. Researchers found a failure rate of 31% in both groups at a median follow-up of 321 days after surgery. Successful cannulation was limited to eight of the 13 AVG patients and eight of the 16 AVF patients. After cannulation, endovascular procedures were performed in 38% of patients in the AVG group and in 44% of patients in the AVF group. Researchers found 23% of patients in the AVG group and 25% of patients in the AVF group had surgical interventions and infections were seen in 23% and 13% of these groups, respectively.
Ultimately, the researchers noted the small sample size prevented them from drawing definitive conclusions between AVG and AVF.
“The pilot trial helped refine study design (eligibility criteria, primary outcome, population set analysis, co-variate adjustment) and study team organizational structure (strategic and operational components) for successful execution of a future multicenter randomized trial,” the researchers determined.
Collapse
Read more about
Click Here to Manage Email Alerts