Fistula First? American surgeons are still last

By Peter Laird

The Fistula First program has substantially improved America’s fistula placement rate to 50.8% which is a laudable accomplishment that will eventually have a positive impact on lowering dialysis related mortality and morbidity. However, although the Fistula First program is dramatically increasing fistula placement in CKD-5 patients, American dialysis patients are still in last place in this one global measurement with Japan leading all nations with an incredible 91-93% fistula rate.

In a recent article listed by DOPPS, one potential reason for our continued last place fistula placement rate may be directly related to the lack of emphasis that vascular surgery training programs place on fistula procedures:

During training, US surgeons created fewer fistulae (US mean = 16 vs. 39-426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere.(Download slide presentation)

It is my opinion that until America’s surgeons put Fistula First into practice during their vascular surgery training, America will fail to recover the preeminence we once held as the leading innovator of dialysis access practices.  The progress to date in improving our fistula placement statistics should not lead us to become complacent with this initial success. America still needs to seek an even higher level of achievement starting first with our vascular surgery training programs.

Comments

[Zach]

I may be wrong, but in Japan, many patients have the arteriovenous fistula created by their own nephrologists.

[Dori]

It is easier to have fistulas in Japan or Europe because DOPPS data show that the blood flow rates for dialysis in those countries are much lower--closer to 250 or 350 than the 500 commonly used in the U.S. So fistulas that work fine there would be "failures" here because US clinics insist on delivering quick, harsh treatments in 3 hours or so 3x/week. It's not just about the surgeons.