should the arteriovenous fistula be created before starting dialysis a decision analytic approach开始透析前动静脉瘘应该创建了一个决策分析方法.pdfVIP

Should the Arteriovenous Fistula Be Created before Starting Dialysis?: A Decision Analytic Approach Swapnil Hiremath1,2,3*, Greg Knoll1,2, Milton C. Weinstein3 1 Division of Nephrology, Kidney Research Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, 2 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, 3 Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America Abstract Background: An arteriovenous fistula (AVF) is considered the vascular access of choice, but uncertainty exists about the optimal time for its creation in pre-dialysis patients. The aim of this study was to determine the optimal vascular access referral strategy for stage 4 (glomerular filtration rate ,30 ml/min/1.73 m2) chronic kidney disease patients using a decision analytic framework. Methods: A Markov model was created to compare two strategies: refer all stage 4 chronic kidney disease patients for an AVF versus wait until the patient starts dialysis. Data from published observational studies were used to estimate the probabilities used in the model. A Markov cohort analysis was used to determine the optimal strategy with life expectancy and quality adjusted life expectancy as the outcomes. Sensitivity analyses, including a probabilistic sensitivity analysis, were performed using Monte Carlo simulation. Results: The wait strategy results in a higher life expectancy (66.6 versus 65.9 months) and quality adjusted life expectancy (38.9 versus 38.5 quality adjusted life months) than immediate AVF creation. It was robust across all the parameters except at higher rates of progression and lower rates of ischemic steal syndrome. Conclusions: Early creation of an AVF, as recommended by most guidelines, may not be the preferred strategy in all pre- di