Vascular access in patients on chronic hemodialysis in the Moscow Region: current state and outlook

Background: The prevalence of chronic kidney disease (CKD) is annually growing worldwide. Stable functioning arteriovenous fistula (AVF) is one of the main prerequisites of survival for patients on chronic hemodialysis (HD). As a rule, available clinical guidelines for creation and maintenance of HD vascular access do not give a clear answer to some important questions. We have summarized and analyzed our experience of the creation and maintenance of the vascular access. Aim: To analyze the results of the creation and maintenance of vascular access in a large population of patients on chronic HD (in the Moscow Region). Materials and methods: We analyzed the results of 3837 surgeries for creation and reconstruction of the vascular access in 1862  patients, performed from 2012 to 2016. Results: The CKD stage 5D incidence has increased from 239 to 391 over the last three years. Currently, 2204  patients are followed up and receiving treatment in 38 outpatient centers. Almost one half of all interventions, 43.5% (1668/3837), has been performed to create AVF. Only one third, i.e. 33% (1266/3837) of them was de novo operations, whereas 10.5% (403/3837) were done to create a new AVF in HD patients after thrombosis of the existing AVF. 15.4%  (590/3837) of the interventions were performed for AVF reconstruction, 4% (154/3837) for AVF closure after successful kidney transplantation, 3.2%  (121/3837) for creation of AVF with vascular graft, 3%  (115/3837) for thrombectomy from the graft, 14.6%  (559/3837) to implant a  permanent central venous catheter (CVC), and 13.6%  (520/3837) for placement of a  temporary CVC. 54.4%  (1012/1862) of the patients had their functional AVF, 2.2% (41/1862) had a vascular graft at the beginning of HD, and one year later, there were 73.8% (1152/1561) and 5.3% (83/1561) of such patients, respectively. The type of vascular access at the start of HD strongly depended on the cause of CKD. 60.4% (192/318) of patients with polycystic kidney disease and 65.1% (181/278) with systemic disease or cancer started HD with the CVC. Oneyear survival of patients who started HD with AVF, who started HD with CVC and switched to AVF, and those who initiated and continued HD with CVC only, was 87.5% (95% confidence interval [CI] 83.5– 90.6), 79.6% [95% CI 72.3–82.5], and 66.4% (95% CI 57–74.2), respectively. The 5-year survival in these groups was 61% (95% CI 51.8–71.9), 53.9% (95% CI 42.5–67), and 31.6%  (95%  CI 21.4–41.4), respectively. At one year, primary and secondary AVF patency amounted to 77.2%  (95%  CI 71.7–81.8) and 87% (95% CI 83.7–89.7), respectively, at 5 years 34.1% (95% CI 27.8–40.5) and 60.9% (95% CI 56.4– 65.1), respectively. Conclusion: A more detailed analysis is necessary to identify risk factors for complications of the vascular access and to optimize approaches to its creation and reconstruction. An effective way to achieve this goal is to establish a local registry of CKD patients.