Should the KDOQI Guidelines for First Time Dialysis Access Apply to All Patients?

Objectives:
The purpose of this study is to analyze the outcomes of patients undergoing arteriovenous fistulas (AVF) versus arteriovenous grafting (AVG) as their first-time permanent access surgery.
Methods;
A retrospective review of all consecutive patients undergoing new, first time access procedures from January to December 2005 was performed. Data was analyzed using standard statistical practices.
Results:
Of 239 patients undergoing first time access procedures, 168 were AVF (70.3%) and 71 were AVG (29.7%). Sixty two percent of the AVF were placed in male and 70.2% of the AVG were in female patients (p<0.0001). The AVF group had 33 primary failures (19.6%) and the AVG group had 6 primary failures (8%) (p=0.02). Primary and primary assisted patency were 23% and 54% in AVF versus 18% and 35% in AVG (p=0.01 and p<0.0001). The secondary patency of 56% and 60%, AVF vs. AVG, was not different. The AVF group had an average intervention rate of 0.91, whereas the AVG group had intervention rate of 1.53 (p<0.001). However, in African American female patients (AAF) primary failure was significantly higher (36% vs. 16.7% p=0.013) than the remaining AVF cohort, primary patency rates were significantly worse (9% vs. 27% p=0.002), and more interventions were required in these patients. African America female patients with AVG had similar patency rates as the rest of the group. Patency rates for AVF and AVG in the AAF were similar statistically.
Conclusions:
Within the constraints of the KDOQI guidelines, African American female patients with AVF had worse outcomes. New algorithms in the management of first time permanent AV access may need to be explored in these complex high risk patients.