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Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach

BACKGROUND: An arteriovenous fistula (AVF) is considered the vascular access of choice, but uncertainty exists about the optimal time for its creation in pre-dialysis patients. The aim of this study was to determine the optimal vascular access referral strategy for stage 4 (glomerular filtration rat...

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Detalles Bibliográficos
Autores principales: Hiremath, Swapnil, Knoll, Greg, Weinstein, Milton C.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2011
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3233576/
https://www.ncbi.nlm.nih.gov/pubmed/22163305
http://dx.doi.org/10.1371/journal.pone.0028453
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author Hiremath, Swapnil
Knoll, Greg
Weinstein, Milton C.
author_facet Hiremath, Swapnil
Knoll, Greg
Weinstein, Milton C.
author_sort Hiremath, Swapnil
collection PubMed
description BACKGROUND: An arteriovenous fistula (AVF) is considered the vascular access of choice, but uncertainty exists about the optimal time for its creation in pre-dialysis patients. The aim of this study was to determine the optimal vascular access referral strategy for stage 4 (glomerular filtration rate <30 ml/min/1.73 m(2)) chronic kidney disease patients using a decision analytic framework. METHODS: A Markov model was created to compare two strategies: refer all stage 4 chronic kidney disease patients for an AVF versus wait until the patient starts dialysis. Data from published observational studies were used to estimate the probabilities used in the model. A Markov cohort analysis was used to determine the optimal strategy with life expectancy and quality adjusted life expectancy as the outcomes. Sensitivity analyses, including a probabilistic sensitivity analysis, were performed using Monte Carlo simulation. RESULTS: The wait strategy results in a higher life expectancy (66.6 versus 65.9 months) and quality adjusted life expectancy (38.9 versus 38.5 quality adjusted life months) than immediate AVF creation. It was robust across all the parameters except at higher rates of progression and lower rates of ischemic steal syndrome. CONCLUSIONS: Early creation of an AVF, as recommended by most guidelines, may not be the preferred strategy in all pre-dialysis patients. Further research on cost implications and patient preferences for treatment options needs to be done before recommending early AVF creation.
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spelling pubmed-32335762011-12-12 Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach Hiremath, Swapnil Knoll, Greg Weinstein, Milton C. PLoS One Research Article BACKGROUND: An arteriovenous fistula (AVF) is considered the vascular access of choice, but uncertainty exists about the optimal time for its creation in pre-dialysis patients. The aim of this study was to determine the optimal vascular access referral strategy for stage 4 (glomerular filtration rate <30 ml/min/1.73 m(2)) chronic kidney disease patients using a decision analytic framework. METHODS: A Markov model was created to compare two strategies: refer all stage 4 chronic kidney disease patients for an AVF versus wait until the patient starts dialysis. Data from published observational studies were used to estimate the probabilities used in the model. A Markov cohort analysis was used to determine the optimal strategy with life expectancy and quality adjusted life expectancy as the outcomes. Sensitivity analyses, including a probabilistic sensitivity analysis, were performed using Monte Carlo simulation. RESULTS: The wait strategy results in a higher life expectancy (66.6 versus 65.9 months) and quality adjusted life expectancy (38.9 versus 38.5 quality adjusted life months) than immediate AVF creation. It was robust across all the parameters except at higher rates of progression and lower rates of ischemic steal syndrome. CONCLUSIONS: Early creation of an AVF, as recommended by most guidelines, may not be the preferred strategy in all pre-dialysis patients. Further research on cost implications and patient preferences for treatment options needs to be done before recommending early AVF creation. Public Library of Science 2011-12-07 /pmc/articles/PMC3233576/ /pubmed/22163305 http://dx.doi.org/10.1371/journal.pone.0028453 Text en Hiremath et al. http://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.
spellingShingle Research Article
Hiremath, Swapnil
Knoll, Greg
Weinstein, Milton C.
Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach
title Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach
title_full Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach
title_fullStr Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach
title_full_unstemmed Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach
title_short Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach
title_sort should the arteriovenous fistula be created before starting dialysis?: a decision analytic approach
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3233576/
https://www.ncbi.nlm.nih.gov/pubmed/22163305
http://dx.doi.org/10.1371/journal.pone.0028453
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