European Journal of Cardiovascular Medicine

Chronic kidney disease (CKD) represents a major global health burden, with increasing numbers of patients requiring renal replacement therapy in the form of haemodialysis [1]. Among the various vascular access options available, arteriovenous fistula (AVF) remains the gold standard due to its superior long-term patency, lower infection rates, and reduced morbidity compared to central venous catheters and grafts [2,3]. The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) strongly recommends AVF as the preferred access modality [4].

Despite its advantages, AVF success is highly dependent on multiple factors including patient characteristics, vascular anatomy, and most importantly, the timing of AVF creation [5]. Early referral to a vascular surgeon and timely creation of AVF before the initiation of maintenance haemodialysis have been associated with improved outcomes [6]. Conversely, patients who undergo AVF creation after initiation of dialysis often rely on temporary central venous catheters, which are associated with higher infection rates and vascular complications [7].

Primary failure of AVF, defined as failure to mature adequately for dialysis use, remains a significant concern, with reported rates ranging from 20% to 50% [8]. Several studies have identified delayed AVF creation and poor vessel quality as key contributors to these failures [9]. Additionally, uraemic milieu and repeated venous cannulations in patients already on dialysis may adversely affect vascular integrity and healing [10].

In India, where late presentation of CKD is common, many patients undergo AVF creation only after initiation of haemodialysis, potentially compromising outcomes. Therefore, evaluating the impact of timing of AVF creation on early outcomes is clinically relevant.

The present study aims to assess early outcomes of AVF creation in a large cohort and compare the success rates, maturation, and complications between patients undergoing AVF creation before and after initiation of maintenance haemodialysis.

This retrospective observational study was conducted at Vascular Care Center, Hyderabad, over a period of 8 months (2018–2019). A total of 1200 patients diagnosed with end-stage renal disease (ESRD) who underwent AVF creation were included. Ethical approval was obtained from the institutional review board.

Patients were divided into two groups:

•              Group A (Pre-dialysis AVF): AVF created before initiation of maintenance haemodialysis

•              Group B (Post-dialysis AVF): AVF created after initiation of haemodialysis

Inclusion criteria included adult patients (>18 years) with ESRD undergoing first-time AVF creation. Patients with prior vascular access surgery, severe peripheral vascular disease, or incomplete records were excluded.

Standard surgical techniques were used for AVF creation, predominantly radiocephalic and brachiocephalic fistulas. Preoperative vascular mapping using Doppler ultrasound was performed in selected cases.

Primary outcomes assessed included:

•              AVF maturation (usable for dialysis within 6–8 weeks)

•              Primary failure

•              Early complications (thrombosis, infection, hematoma)

Data were analyzed using SPSS version 22. Continuous variables were expressed as mean ± SD, and categorical variables as percentages. Chi-square test was used for categorical variables and independent t-test for continuous variables. A p-value <0.05 was considered statistically significant.

Overall Outcome

Among 1200 patients, 60% underwent AVF creation prior to dialysis initiation. The pre-dialysis group demonstrated significantly better maturation rates and lower complication rates compared to the post-dialysis group. Early AVF failure and thrombosis were notably higher in patients who underwent AVF after initiation of haemodialysis.

Table 1

The distribution of patients showed a predominance of pre-dialysis AVF creation (60%) compared to post-dialysis AVF (40%). This reflects improved awareness and early referral patterns in a significant proportion of patients. However, a substantial number still undergo delayed access creation, highlighting gaps in CKD management pathways.

Table 1. Distribution of Study Population (n=1200)

Table 2

AVF maturation was significantly higher in patients who underwent fistula creation before initiation of dialysis (88.5%) compared to those after dialysis initiation (72.1%). The difference was statistically highly significant (p<0.001), emphasizing the importance of early vascular access planning.

Table 2. AVF Maturation Rates

Table 3                      

Primary AVF failure was significantly lower in the pre-dialysis group (8.2%) compared to the post-dialysis group (21.5%). This difference indicates that vascular condition and timing of intervention play critical roles in determining AVF success.

Table 3. Primary Failure Rates

Table 4

Complication rates including thrombosis and infection were significantly higher in patients undergoing AVF after dialysis initiation. Thrombosis was the most common complication, reflecting compromised vascular integrity in these patients.

Table 4. Early Complications

The present study demonstrates that early AVF creation prior to initiation of haemodialysis is associated with significantly better outcomes compared to delayed AVF creation. These findings are consistent with established literature emphasizing the benefits of timely vascular access planning.

AVF maturation rates in this study (88.5% in pre-dialysis group) are comparable to those reported by Dember LM et al., who highlighted improved outcomes with early referral and vascular mapping [11]. Similarly, Lok CE et al. reported that delayed AVF creation is associated with increased primary failure rates, corroborating the findings of the present study [12].

Primary failure rates observed in the post-dialysis group (21.5%) align with previous reports suggesting that uraemia and repeated venous cannulation negatively impact vascular remodeling and endothelial function [13]. Allon M et al. emphasized that vascular injury and inflammation in dialysis patients contribute to reduced AVF success [14].

The higher complication rates observed in the post-dialysis group, particularly thrombosis and infection, are consistent with studies by Pisoni RL et al., who demonstrated increased morbidity associated with delayed AVF creation [15]. Central venous catheter dependence prior to AVF maturation further exacerbates infection risk and vascular damage [16].

The findings also reinforce KDOQI recommendations advocating early AVF placement to minimize catheter use and improve long-term outcomes [17]. Early referral allows adequate time for AVF maturation and reduces emergency access procedures.

In the Indian context, late presentation of CKD patients remains a significant challenge, often resulting in delayed AVF creation. Socioeconomic factors, lack of awareness, and limited access to specialized vascular services contribute to this issue [18]. The present study highlights the need for improved CKD screening programs and early nephrology referral.

From a surgical perspective, better vessel quality in pre-dialysis patients likely contributes to improved outcomes. Studies have shown that arterial and venous diameters, along with endothelial health, are critical determinants of AVF success [19].

The large sample size (1200 patients) strengthens the validity of the findings. However, limitations include the retrospective design and lack of long-term follow-up data. Future prospective studies are required to evaluate long-term patency and functional outcomes.

This study demonstrates that early creation of arteriovenous fistula prior to initiation of maintenance haemodialysis significantly improves early outcomes, including higher maturation rates and lower primary failure and complication rates. Patients undergoing AVF after initiation of dialysis exhibit poorer outcomes, likely due to compromised vascular integrity and catheter-related complications.

The findings strongly support early referral of CKD patients for vascular access planning and adherence to established guidelines. Implementing structured CKD care pathways and increasing awareness among healthcare providers can facilitate timely AVF creation.

Early AVF placement should be considered a critical component of pre-dialysis care to optimize patient outcomes, reduce morbidity, and improve the overall efficiency of haemodialysis programs.

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