America Still Struggles to Accept Fistula First Initiative
By Peter Laird, MD
CJASN has a recent article calling for more studies on fistula vs grafts before adopting further measures of the Fistula First initiative. Fistulas once matured have a much lower incidence of complications than grafts or catheters, yet America has been a long time outlier on fistula usage compared to the rest of the developed world. At the start of hemodialysis in America, only 52% of patients have a functioning fistula. On the other hand, Belgium and Italy have 100% fistula rate at onset of dialysis with Japan right behind them at 99%. Previous studies from DOPPS have shown that our lack of attention to fistula creation during vascular surgery training plays a role in these disparities.
Enhanced Training in Vascular Access Creation Predicts Arteriovenous Fistula Placement and Patency in Hemodialysis Patients:
Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created >/=25 (vs. <25) fistulae during training. CONCLUSIONS: Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.
One of the differences between what is considered mature fistulas in Europe and America is the difference in clinical practice for dialysis blood flow rates which are significantly higher in America fixated on rapid, “efficient” dialysis sessions predicated on our business model of dialysis care. Many fistulas deemed inadequate in America would work well in the European model of dialysis care with lower blood flow rates. I cannot agree with the authors call in the CJASN article that there is equipoise between grafts and fistulas justifying randomized and controlled trials on their use since this is a uniquely America difficulty based on both our clinical practice patterns and our lack of training compared to all other developed nations.
Perhaps instead of calling for further studies between grafts vs fistulas, America might actually learn from those nations with a 100% fistula rate what we are doing wrong here only in America before blaming the procedure itself for our own failings. It is time for American dialysis practitioners to look beyond our own egocentric views of dialysis practice and join the rest of the world with more optimal outcomes in all aspects of dialysis care.
http://www.hemodoc.com/2011/01/america-still-struggles-to-accept-fistula-first.html