Early ultrasound surveillance of newly-created haemodialysis arteriovenous fistula

Richards, James; Summers, Dominic; Sidders, Anna; Allen, Elisa; Thomas, Helen; Hossain, Mohammed Ayaz; Paul, Subhankar; Slater, Matthew; Bartlett, Matthew; Lagaac, Regin; Laing, Emma; Hopkins, Valerie; Fitzpatrick-Creamer, Chloe; Hudson, Cara; Parsons, Joseph; Turner, Sam; Tambyraja, Andrew; Somalanka, Subash; Hunter, James; Dutta, Sam; Hoye, Neil; Lawman, Sarah; Salter, Tracey; Aslam, Mohammed; Bagul, Atul; Sivaprakasam, Rajesh; Smith, George; Moinuddin, Zia; Knight, Simon; Barnett, Nicholas; Motallebzadeh, Reza; Pettigrew, Gavin J.; Sidders, Anna; Hudson, Cara; Foley, Claire; Hopkins, Valerie; Laing, Emma; Fitzpatrick-Creamer, Chloe; Thomas, Helen; Deary, Alison; Pettigrew, Gavin J.; Richards, James; Hossain, Mohammed; Summers, Dominic; Slater, Matthew; Scott, Laura; Lagaac, Regin; Surendrakumar, Veena; Ayorinde, Tobi; Chipurovski, Igor; Kathirvel, Manikandan; Thialli, Manoj; Paul, Subhankar; Norton, Andrew; Knight, Simon; Bond, Klaus; Hardy, Elizabeth; Widdup, Joanne; Potter, Rachae...

Abstract

Introduction
We assess if ultrasound surveillance of newly-created arteriovenous fistulas (AVFs) can predict nonmaturation sufficiently reliably to justify randomized controlled trial (RCT) evaluation of ultrasound-directed salvage intervention.
Methods
Consenting adults underwent blinded fortnightly ultrasound scanning of their AVF after creation, with scan characteristics that predicted AVF nonmaturation identified by logistic regression modeling.
Results
Of 333 AVFs created, 65.8% matured by 10 weeks. Serial scanning revealed that maturation occurred rapidly, whereas consistently lower fistula flow rates and venous diameters were observed in those that did not mature. Wrist and elbow AVF nonmaturation could be optimally modeled from week 4 ultrasound parameters alone, but with only moderate positive predictive values (PPVs) (wrist, 60.6% [95% confidence interval, CI: 43.9–77.3]; elbow, 66.7% [48.9–84.4]). Moreover, 40 (70.2%) of the 57 AVFs that thrombosed by week 10 had already failed by the week 4 scan, thus limiting the potential of salvage procedures initiated by that scan’s findings to alter overall maturation rates. Modeling of the early ultrasound characteristics could also predict primary patency failure at 6 months; however, that model performed poorly at predicting assisted primary failure (those AVFs that failed despite a salvage attempt), partly because patency of at-risk AVFs was maintained by successful salvage performed without recourse to the early scan data.
Conclusion
Early ultrasound surveillance may predict fistula maturation, but is likely, at best, to result in only very modest improvements in fistula patency. Power calculations suggest that an impractically large number of participants (>1700) would be required for formal RCT evaluation.

Citation

Richards, J., Summers, D., Sidders, A., Allen, E., Thomas, H., Hossain, M. A., …Walker, A. (2024). Early ultrasound surveillance of newly-created haemodialysis arteriovenous fistula. Kidney International Reports, 9(4), 1005-1019. https://doi.org/10.1016/j.ekir.2024.01.011

• Journal Article Type: Article
• Acceptance Date: Jan 2, 2024
• Online Publication Date: Jan 5, 2024
• Publication Date: Apr 1, 2024
• Deposit Date: Jan 9, 2024
• Publicly Available Date: Apr 5, 2024
• Journal: Kidney International Reports
• Print ISSN: 2468-0249
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 9
• Issue: 4
• Pages: 1005-1019
• DOI: https://doi.org/10.1016/j.ekir.2024.01.011
• Keywords: Arteriovenous fistula; Renal dialysis; Ultrasonography; Doppler; Kidney failure; chronic: Haemodialysis; Vascular access surgery
• Public URL: https://hull-repository.worktribe.com/output/4508478