Early failure is a major issue in dialysis patients receiving an arteriovenous fistula. It is associated with increased morbidity and costs of medical care. Previously, Lok et al made an attempt to identify preoperative clinical characteristics that predicted fistula maturation failure. However, a recent publication in the American Journal of Kidney Diseases by Lilly et al  highlights that such prediction equations are much more complex than was previously believed. Using a large sample of 195,756 adult patients initiating hemodialysis in the United States, these investigators emphasize that preoperative clinical factors have very limited predictive capability. Among other factors, they indicate that surgical expertise on the outcome of a fistula cannot be ignored. From a clinical standpoint, I believe that this part of the equation must be balanced. Choi et al have previously reported on differences in the incidence of early failure between the two dedicated vascular access surgeons serving their patients. In that study, surgeon 1 had an early failure rate of 5%, while surgeon 2 had a rate of 31% (P = 0.002). The demographic characteristics of the patients as well as the vessel mapping results in the two groups were essentially the same. With the availability of such information, the expertise of the operating surgeon becomes an important factor. Related to surgical expertise is another factor that is worth mentioning. It appears that different anastomotic configurations may also have an influence on the ultimate outcome of the fistula. It is also important to point out that the impact of early referral to a nephrologist as highlighted by Lilly et al cannot be overemphasized. Finally, evaluation of the patient by a surgeon with expertise in fistula surgery in light of the Fistula First Breakthrough Initiative would serve the patient well.

 Arif Asif, MD

Professor of Medicine and Director of Interventional Nephrology, University of Miami Miller School of Medicine; AJKD Associate Editor

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