Division of Nephrology, London Health Sciences Center and the University of Western Ontario, London, ON, Canada.
Nephrol Dial Transplant. 2010 Aug;25(8):2644-51. doi: 10.1093/ndt/gfq064. Epub 2010 Feb 22.
There is marked variation in the use of the arteriovenous fistula (AVF) across programmes, regions and countries not explained by differences in patient demographics or comorbidities. The lack of clear criteria of who should or should not get a fistula may contribute to this, as well as barriers to creating AVFs.
We conducted a survey of Canadian and American nephrologists to assess the patient variables considered to determine the timing and type of access requested. Perceived barriers and absolute contraindications to access were also collected.
An immediate referral for a fistula was more highly preferred when patients are <65 years old, have minimal comorbidities or have no history of failed accesses. In older patients, and in those with increased comorbidities or a previously failed fistula, US nephrologists selected arteriovenous grafts as an alternative to the fistula, while Canadian nephrologists selected primarily catheters. Referral for vascular mapping was more common in the USA than in Canada. Gender did not influence the timing or the type of access. Perceived barriers to establishing a mature fistula included patient refusal for creation (77%) or cannulation (58%), delay in decision regarding dialysis modality (71%), wait time for surgical creation (55%) and high failure-to-mature rate (52%). We found that 27% of Canadian and 43% of American nephrologists indicated no absolute contraindications for permanent vascular access.
This study demonstrated marked variability in timing and criteria used to select patients for referral for a vascular access between nephrologists practicing within Canada and the USA. Establishing minimal eligibility criteria for fistulae is an important area of future research.
动静脉瘘（AVF）的使用在不同的项目、地区和国家之间存在显著差异，这种差异不能用患者人口统计学特征或合并症的差异来解释。缺乏明确的标准来确定谁应该或不应该获得瘘管，这可能是造成这种差异的原因之一，此外，创建 AVF 也存在障碍。
我们对加拿大和美国的肾病学家进行了一项调查，以评估用于确定请求血管通路的时间和类型的患者变量。还收集了对血管通路的感知障碍和绝对禁忌证。
当患者年龄<65 岁、合并症较少或没有血管通路失败史时，更倾向于立即转介进行瘘管。在老年患者和合并症较多或先前瘘管失败的患者中，美国肾病学家选择动静脉移植物作为瘘管的替代物，而加拿大肾病学家主要选择导管。与加拿大相比，美国更常进行血管造影以转介。性别并不影响血管通路的时机或类型。建立成熟瘘管的感知障碍包括患者拒绝造瘘（77%）或插管（58%）、对透析方式的决策延迟（71%）、手术造瘘等待时间（55%）和高成熟失败率（52%）。我们发现，27%的加拿大肾病学家和 43%的美国肾病学家表示对永久性血管通路没有绝对禁忌证。
这项研究表明，在加拿大和美国的肾病学家中，在为血管通路转介患者的时机和标准方面存在显著差异。确定瘘管的最低资格标准是未来研究的一个重要领域。
