The Arteriovenous Fistula and Progression of Kidney Disease

In 1978, Bill Bennett hired me to “do academic dialysis.” As part of the first National Kidney Foundation Dialysis Outcome Quality Initiative  Clinical Practice Guideline leadership team, I became more interested in hemodialysis vascular access. I designed and placed “save the vessels” bracelets for our patients to wear protecting vessels. When I considered hemodialysis to be likely within 12 months, I strongly encouraged creation of arteriovenous fistulae (AVFs). I delayed arteriovenous graft (AVG) placement until much closer to the expected hemodialysis initiation date. Over 35 years I noticed that a significant fraction of patients with functioning AVFs seemed to slow the decline in their rate of eGFR. In a simple proof-of-concept retrospective observational study, it appeared that eGFR decline did display a slowing after AVF creation (1). Subsequent better-designed studies corroborated our findings (2⇓⇓–5). Although fraught with methodological problems, one study suggested that even placing a peritoneal dialysis catheter slowed progression (4). This did not make physiologic sense to me. In this issue of Kidney360 , another study from Montreal dispels the notion that placing of a peritoneal dialysis catheter affects eGFR decline (5).Sumida et al. utilized a Veterans Administration database, which included AVGs and AVFs with over 3000 patients, not limited by AVF maturation, and used central venous catheter recipients as propensity-matched controls (2). AVF and AVG recipients showed eGFR deceleration after surgical creation, independent of maturation, whereas our study only evaluated maturing AVFs. The first Montreal paper precisely defined the cohort, its clinical characteristics, tried to adjust for known confounders, and used maturation for inclusion (3). Attenuation of eGFR decline over time was again noted after AVF creation. At about the same time, Lundstrom et al. (4) were utilizing a Swedish national database and used patients with peritoneal dialysis catheters as comparators …