1. Analysis of Risk Factors for Early Access Failure of AVF in Patients on Hemodialysis 경희 대학교 의과대학 내과학교실 문수연, 박병조, 이향이, 정경환, 김정희, 이상호, 이태원, 임천규, 김명재

2. Background End-stage renal disease – Dialysis: HD (60.2%) > PD (17.5%) (Renal replacement therapy in Korea – Insan Memorial Dialysis Registry 2003) – AV fistula vs AV graft Early access failure of AVF(~ 30%) – Definition AVF never develops to the point used AVF fails within first 3 months of surgery (Semin Dial 2000, 13)

3. Risk factors of early access failure of AVF – Local risk factors Blood flow at AVF access site – < 700 mL/min – risk for early access failure (Nephrol Dial Transplant, 2004, 19) Diameter of artery and vein – < 1.6 mm – risk for early access failure (Eur J Endovasc Surg, 1996, 12) Doppler US – Systemic factors → risk factor ?

4. Aim To evaluate rate of early access failure of AVF To evaluate systemic risk factors for early access failure of AVF

5. Subjects and Methods Subjects – 1999. 3 ~ 2004. 3 – 111 patients with ESRD – Vascular access surgery and HD at KHMC Methods – Medical record by reviewing the charts – Statistic analysis

6. Methods Medical records – Causes of CKD, history of cardiovascular events – History of ipsilateral central venous catheter insertion – Laboratory finding at the time of surgery CBC/DC (hemoglobin, hematocrit) Calcium, phosphorus, parathyroid hormone, albumin – Medication history Aspirin, warfarin, clopidogrel, etc HMG-CoA reductase inhibitor ACEi or ARB

7. Results

8. Table 1. Type of vascular access of subjects AV fistulaAV graft Age (years)49.2 ± 15.152.1 ± 13.3 Sex (M/F)60/6711/15 Total number12726 Primary choice1056 Early access failure (%)27 (21.3%)2 (7.7%)

9. Table 2. Baseline characteristics of patients with AVF Early access failureYes (n=27)No (n=100)p-value Age (years, mean ± SD)51.4 ± 15.748.6 ± 15.0 ≤ 508540.025 > 501946 Sex (M/F)15/1245/550.33 Causes of CKD DM11(40.7%)29(29.0%)0.24 Hypertension6(22.2%)29(29.0%)0.48 Glomerulonephritis5(18.5%)14(14.0%)0.56 Unknown3(11.1%)19(19.0%)0.34 Others2(7.4%)9(9.0%)0.79 History of cardiovascular events (%) 3(11.1%)2(2.0%)0.03 History of ipsilateral central catheter insertion (%) 9(33.3%)8(8.1%)0.001

10. Table 3. Medication history Early access failiureYes (n=27)No (n=100)p-value Anticoagulants & antiplatelet agents19(70.4%)38(39.6%)0.008 Aspirin1627 Warfarin30 Clopidogrel, persantin, ect1420 ACEi or ARB (%)7(25.9%)26(27.1%)0.91 HMG-CoA reductase inhibitor020.56

11. Table 4. Laboratory findings Early access failureYes (n=27)No (n=100)p-value Hemoglobin8.9 ± 1.57.9 ± 1.6 ≤ 8 mg/dL7560.001 > 8 mg/dL2035 Hematocrit26.3 ± 4.523.5 ± 4.7 ≤ 25%10650.001 > 25%1726 Calcium8.5 ± 1.28.2 ± 1.2 ≤ 8.3 mg/dL15470.62 > 8.3 mg/dL1143 Phosphorus5.8 ± 2.25.6 ± 2.0 ≤ 5.7 mg/dL14520.63 > 5.7 mg/dL1236 Ca X P ≤ 365260.28 > 361961 Albumin3.5 ± 0.13.5 ± 0.7 ≤ 3 g/dL3270.055 > 3 g/dL2362 PTH154.1 ± 181.3162.1 ± 218.0 ≤ 154.00 pg/mL14440.66 > 154.00 pg/mL624

12. Table 5. Multivariate anaylsis of risk factors for early access failure of AVF Odd ratio 95.0% C.I. for Odd ratio Sig. Lower Upper Age at the time of surgery 2.440.639.39.194 Sex 0.690.212.20.525 DM 2.060.528.19.305 HTN 0.710.212.47.597 History of cardiovascular event 3.530.2746.33.337 History of ipsilateral central catheter insertion 5.461.1525.85.033 Hemoglobin 5.041.4817.11.010 Albumin 6.911.1740.86.033 Ca X P 0.630.162.52.510 Phosphorus 1.330.404.42.635

13. Summary Factors not related to early access failure of AVF – Sex, DM, HTN, PTH, Ca, P, Ca X P, ACEi or ARB, and HMG-CoA reductase inhibitor Factors related to early access failure of AVF – Univariate analysis Old age, history of ipsilateral central catheter insertion, history of cardiovascular events, and higher level of hemoglobin and hematocrit – Multivariate analysis History of ipsilateral central venous catheter insertion, and higher hemoglobin and albumin

14. Conclusion History of ipsilateral central venous catheter insertion, and higher hemoglobin and albumin – independent risk factor for early access failure of AVF