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Should DOQI Guidelines For Access Creation Be Modified For Women?

Anantha K Ramanathan¹, Nader S Nader¹, Maciej C Dryjski¹, Richard G Curl², Hasan H Dosluoglu¹, Gregory S Cherr¹, Alan S Kuritzky¹, Linda M Harris.^1
1University at Buffalo, Buffalo, NY; ²Buffalo Medical Group, Buffalo, NY.

OBJECTIVES: Use of an aggressive approach to autologous fistula creation with a specified order has been accepted for dialysis access. Women fare worse than men with access patency. The purpose of this study is to review autogenous fistulas in women to determine whether type of fistula might improve patency.

METHODS: We retrospectively collected data from patient charts and dialysis records for all patients at a university hospital undergoing fistulae creation between 2001 and 2005. Type of access was determined by physician preference and preceded by duplex evaluation in 84.3%. Data included demographics, comorbidities, patency, and need for reintervention. Univariate and multivariate analyses were performed using SPSS (Chicago, Illinois). Life tables were utilized to calculate patency rates and the Wilcoxon Gehan test was used to compare patency curves. Significance was taken at p < 0.05.

RESULTS:156 patients (88 males; 68 females) underwent creation of 172 fistulae (92 males; 80 females). Mean follow up was 78 +/- 55.6 weeks. Comorbidities and demographics were similar among males and females except for cardiac arrhythmias (38.6% vs. 23.5%; p=0.033) and diabetes (52.3% vs. 69.1%; p=0.024), and did not affect patency. Primary failure (before use) was associated with access site (wrist vs. arm, p=0.01), fistula type (cephalic vs. basilic, p=0.011) and gender (female vs. male, p=0.001) by univariate analysis. Access occlusion within 1 year was associated with site (forearm, p=0.009), cephalic vein (p=0.02) and female gender (p=0.026). Women had worse primary (p=0.03), assisted primary (p=0.002) and secondary (p=0.001) patency rates than men. Brachiobasilic fistula (BBF) in women fared significantly better than other types of fistulae (table 1). Figure 1 shows overall patency rates by fistula type in men and women.

CONCLUSIONS: Women have a worse overall fistula patency rate as compared to men. The brachiobasilic fistula had a better rate of patency than the radiocephalic or brachiocephalic in women. Further evaluation is needed to determine whether the DOQI guidelines regarding order of choice for access creation should be altered for women, with brachiobasilic fistula being considered as a first tier procedure.