The haemodialysis arteriovenous graft: is a new era coming?

The worldwide increase in the incidence and prevalence of haemodialysis (HD) patients is determining the growing demand of vascular access (VA) placement [1]. It is also wellknown that the VA issue imposes a major financial burden on healthcare systems and can be associated with increased morbidity and mortality [2]. VA dysfunction is a major cause of morbidity and mortality in HD patients [3]. Between the Fistula First Breakthrough Initiative [4] and strategies for decreasing the use of HD catheters, ‘fistula first/ catheter last’ [5], there is a renewed research effort aimed at improving the poor outcomes of arteriovenous graft (AVG). In fact, the major disadvantages of synthetic AVGs include the development of graft stenosis, a 5-fold increase in infection risk, a poorer long-term patency, higher levels of complications and more interventions than autogenous arteriovenous fistulas (AVFs) [6]. At the present time, for nephrologists, AVG means reduced primary patency rates, hospitalizations, use of central vein catheters, invasive surgical or less invasive interventional procedures, increased morbidity and mortality beyond the aspect of increase in costs. In this issue of Nephrology Dialysis Transplantation, Paulson et al. [7] provide evidence that an easily clinically applicable therapy, such as the periadventitial delivery of sirolimus, may improve HD graft patency and prolong its functional life.