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In 800 Arteriovenous Fistulas, Anatomy Trumps HbA1C
Gear T Vincent, Mia Cranmer, Patrick Sowa, David Dexter, Hosam El Sayed, Jean Panneton
Eastern Virginia Medical School, Norfolk, VA
Background:Arteriovenous fistula (AVF) creation remains the preferred method for dialysis access in patients with end-stage renal disease (ESRD). While various studies have linked AVF maturation failure to poor glycemic control, the role of diabetes, specifically HbA1C levels, in AVF outcomes remains unclear. This study aims to assess AVF maturation rates in patients with type 2 diabetes (DM2) according to their method of glycemic management.
Methods:We retrospectively reviewed all patients who underwent de novo AV access creation from January 1, 2008, through November 31, 2021, across our multi-hospital network. Exclusion criteria included patients younger than 18 years, those with type 1 diabetes, prior AV access for hemodialysis, or lack of clear access outcomes. Patients who received non-autogenous grafts were also excluded. The remaining cohort was divided into diabetic and non-diabetic subgroups, further stratified by diabetes management: diet, oral medication, or insulin. The primary outcome was successful AVF maturation, defined as explicit approval for cannulation by a vascular surgeon or documented successful cannulation in the patient chart. Secondary outcomes included the rate of successful assisted maturation, which was defined as requiring additional procedures beyond the initial surgical plan.
Results:Of the 830 patients reviewed, maturation data was available for 817. Successful maturation was achieved in 584 (71.5%) patients, with an average maturation time of 87.9 days (SD=90.4 days). Among those, 35.3% were non-diabetic (n=206), and 64.7% had DM2 (n=378). There was no significant difference in maturation or assisted maturation rates between non-diabetic and diabetic patients (p=0.52, p=0.19). Additionally, no significant differences in maturation rates were observed based on the method of diabetes control. Analysis of 713 collected HbA1C values showed no significant correlation with AVF maturation outcomes (p=0.117). While HbA1C values were slightly higher in patients who required assisted maturation (one-sided t-test: p=0.046), the confidence interval limits the clinical relevance of this finding. AROC analysis further indicated that HbA1C had poor discriminative ability for predicting maturation (AUC=0.51). In multivariate logistic regression, arterial diameter was the only significant factor associated with AVF maturation (p<.001).
Conclusions:Diabetes has been traditionally viewed as a risk factor for poor AV access outcomes. However, this large, multi-hospital review demonstrates that AVF maturation rates are independent of diabetic status and method of glycemic control. HbA1C levels were not associated with AVF maturation failure. Our findings suggest that anatomical factors, particularly arterial diameter, play a far more critical role in predicting AVF maturation. This underscores the importance of thorough preoperative vessel mapping to optimize AVF outcomes.
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