America Still Struggles to Accept Fistula First Initiative

By Peter Laird, MD

CJASN has a recent article calling for more studies on fistula vs grafts before adopting further measures of the Fistula First initiative.  Fistulas once matured have a much lower incidence of complications than grafts or catheters, yet America has been a long time outlier on fistula usage compared to the rest of the developed world. At the start of hemodialysis in America, only 52% of patients have a functioning fistula. On the other hand, Belgium and Italy have 100% fistula rate at onset of dialysis with Japan right behind them at 99%.  Previous studies from DOPPS have shown that our lack of attention to fistula creation during vascular surgery training plays a role in these disparities.

Enhanced Training in Vascular Access Creation Predicts Arteriovenous Fistula Placement and Patency in Hemodialysis Patients: 

Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created >/=25 (vs. <25) fistulae during training. CONCLUSIONS: Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.

One of the differences between what is considered mature fistulas in Europe and America is the difference in clinical practice for dialysis blood flow rates which are significantly higher in America fixated on rapid, "efficient" dialysis sessions predicated on our business model of dialysis care. Many fistulas deemed inadequate in America would work well in the European model of dialysis care with lower blood flow rates.  I cannot agree with the authors call in the CJASN article that there is equipoise between grafts and fistulas justifying randomized and controlled trials on their use since this is a uniquely America difficulty based on both our clinical practice patterns and our lack of training compared to all other developed nations.

Perhaps instead of calling for further studies between grafts vs fistulas, America might actually learn from those nations with a 100% fistula rate what we are doing wrong here only in America before blaming the procedure itself for our own failings.  It is time for American dialysis practitioners to look beyond our own egocentric views of dialysis practice and join the rest of the world with more optimal outcomes in all aspects of dialysis care.

Comments

[roberta mikles]

Just amazing that the United States is so far behind other countries... makes one wonder.

Roberta Mikles
Dialysis Patient Safety Advocate
www.qualitysafepatientcare.com

[Sharon Zentgraf]

How fortunate I feel for my husband who is a retired marine. His fistula was created four years prior to being needed. Thanks to the foresight of the excellent medical professionals treating him in the military.

Sharon Zentgraf
Caregiver and Advocate for my husband

[Peter Laird, MD]

Thank you Sharon, I grew up so to speak in military medicine through the Health Professionals Scholarship Program through the military. At the time I went through the program, we had a lot of great training facilities that appear to be going through their own disrepair at present, but 20 years ago, it was a great program.

I miss greatly the days of my military service in medicine where we had dedicated professionals with only one task at hand, offering the best medical care we could to our troops, retirees and dependents. To that effect, I believe we did quite well and it is an experience that served me well once I left the military.

Glad to hear reports that they are still taking good care of folks. Thanks for the update,

Peter

[medyum isimleri izmir]

I miss greatly the days of my military service in medicine where we had dedicated professionals with only one task at hand, offering the best medical care we could to our troops, retirees and dependents. To that effect, I believe we did quite well and it is an experience that served me well once I left the military. xdfgsdg

[Peter Laird, MD]

I can't echo that sentiment enough after spending 9 years in military medicine myself. Money was not the object. Doing the best for each patient was. In many ways, my 9 years in military medicine was without a doubt, the highlight of my medical career. Sadly, the world of for-profit medicine is tainted by greed and conflicts of interest. The dialysis industry is perhaps the epitome of that paradigm. It simply goes against all of the fiduciary trust empowered to doctors. Thanks for commenting and reminding me of those "glory" days I spent in our military medical service.