Thrombophilia and arteriovenous fistula survival in ESRD

Birgitta Salmela, Jari Hartman, Seija Peltonen, Anders Albäck, Riitta Lassila, Birgitta Salmela, Jari Hartman, Seija Peltonen, Anders Albäck, Riitta Lassila

Abstract

Background and objectives: The role of thrombophilia in failing arteriovenous fistula (AVF) among patients with ESRD undergoing hemodialysis is not established. This study aimed to assess whether AVF primary patency is associated with thrombophilia and coagulation abnormalities.

Design, setting, participants, & measurements: This observational study screened 219 patients between 2002 and 2004 for thrombophilia before AVF surgery. Thrombophilia included factor V Leiden and prothrombin G20210A mutations, protein C and antithrombin activities, and protein S. Coagulation abnormalities included high factor VIII:C, homocysteine, fibrinogen, and d-dimer levels; presence of antiphospholipid antibodies; and short thrombin time. We reviewed patient charts for comorbid conditions, AVF maturation and interventions, kidney transplantation, and patient survival (mean follow-up duration, 3.6 [range, 2.3-5.8] years). Primary patency from the AVF placement and functional primary patency from the first AVF cannulation were analyzed with Kaplan-Meier and Cox proportional hazards models.

Results: Thrombophilia was present in 9% of the patients, and coagulation abnormalities occurred in 77%. One-year primary patency was 68%; 46% of the AVF failures occurred before the initiation of hemodialysis. Female sex (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.7-4.1) and thrombophilia (HR, 2.2; 95% CI, 1.2-4.2) were independent risk factors for loss of primary patency. Thrombophilia mutations or low antithrombin level (HR, 3.8), female sex (HR, 2.5), and diabetes (HR, 1.9) were associated with shortened functional primary patency of AVF.

Conclusions: Against the background of frequent coagulation abnormalities, thrombophilia and female sex predispose patients with ESRD to access failure, mostly due to thrombosis or stenosis.

Figures

Figure 1.
Figure 1.
Primary and functional primary patency of arteriovenous fistula (AVF). (A) AVF survival after the placement of the fistula in 219 patients. (B) Functional AVF survival after the initial fistula cannulation among the 180 patients in whom hemodialysis could be initiated. Success rates are shown at 1 year and at the end of follow-up (mean, 3.6 years).
Figure 2.
Figure 2.
Cumulative arteriovenous fistula survival among patients with (TF+) and without (TF-) thrombophilia. Female sex (P<0.001) and the presence of thrombophilia (P=0.02) were associated with significantly shortened primary patency of arteriovenous fistula. Thrombophilia included factor V Leiden and prothrombin mutations and low levels of natural anticoagulants (antithrombin, protein C, and protein S) (see Materials and Methods).

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