NDT Advance Access originally published online on July 5, 2005
Nephrology Dialysis Transplantation 2005 20(9):2011; doi:10.1093/ndt/gfh952
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Reply
Sir,We read with interest the Letter by Diskin and Stokes and would like to thank them for the interest in our paper. In their article, the authors report their previous experience on the importance of cannulation delay of a vascular access [1]. This paper was more in agreement with the results of Saran et al. [2] than with ours. More importantly, their results were not based upon a questionnaire of different centres, but they performed an actual analysis (to the very day) of the survival of each patient's access. In the paper, the number of patients with a native artero-venous fistulae is not reported, nor the number of patients with a vascular graft. Furthermore, no data were reported about the age and the risk factors of this population. It is clear that a graft can require a shorter period for postponing cannulation than a native fistula. Usually, graft can be used 2 weeks after creation. A higher number of patients with a graft compared to our population could be the reason for the fact that the authors did not observe any effect on survival of vascular access in postponing first cannulation after creation. When we analysed our data, cannulation earlier than 1 month was associated with a 94% higher risk of primary failure (P<0.001), whereas cannulation earlier than 2 weeks increased the risk of final failure by 111% (P<0.009). Other additional independent and significant predictors of failure were nephrology referral within 3 months of dialysis start and presence of cardiovascular disease in the primary survival model (independent of catheter use); catheter utilization at the start of dialysis; and the presence of cardiovascular disease (in the secondary survival model). We concluded that late referral and the use of catheters predict shorter AVF survival not only through earlier cannulation [2]. We agree with Diskin and Stokes that early cannulation is not for every access, but skilled nurses and nephrologists can distinguish between those fistulae that may be safely cannulated and those which cannot. On the other hand, we are now dealing with older patients [3] and a complete maturation of a vascular access can require more time than an access in a younger patient. It is possible that a fistula can be cannulated after 2 weeks, but the risk of a failure is very high. Late referral patients, dialyzed via a catheter, have a high risk of infection and sometimes in these patients we perform an early cannulation, in order to reduce the risk of infection. But, at the same time, we increase the risk of early failure. It is clear that we must make all possible efforts to reduce the number of late referral patients, in order to create a timely vascular access.
Conflict of interest statement. None declared.
Cattedra di Nefrologia Università di Brescia Brescia Italy Email: gcbrunori{at}hotmail.com
References
- Diskin CJ, Stokes TJ, Panus LW. The importance in delay in cannulation after hemodialysis vascular access surgery. Nephron 1996; 74: 245–249[Medline]
- Ravani P, Brunori G, Mandolfo S et al. Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study. J Am Soc Nephrol 2004; 15: 204–209
[Abstract/Free Full Text] - Stengel B, Billon S, Van Djik PC et al. Trends in the incidence of renal replacement therapy for end-stage renal disease in Europe, 1990–1999. Nephrol Dial Transplant 2003; 18: 1824–1833
[Abstract/Free Full Text]
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