AVF Inventor Kenneth Appell Discusses Fistula's Limitations

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Dr. Kenneth Appell remains engaged in current medical developments and thinking, and recently had an interesting exchange with Long Island, NY nephrologist Simon E. Prince, who industriously and informatively puts out The Nephrology Blog. This past February 25, Dr. Prince added the following post:

Vascular Access Controversies

The Renal Business Today website has an interesting 'roundtable' discussion on Vascular access today.

This follows the excellent thought-provoking recent videoblog of Dr Berns: AV Access and Fistula First? This is then followed by some excellent comments from the nephrology community.

I support Fistula First. But also, I believe an AVF is not always appropriate. I believe the rhetoric can be toned down a notch. Dialysis units are incentivized to have a higher %AVF, and it although it is undoubetdly usually the best option... it is not always the best option for each individual patient.

Some examples where Fistula First may not be best:

1) Potentially reversible disease. There are instances of acute renal failure which requires dialysis, but recovery is anticipated... or at least possible.

2) Poor life expectancy. Some of our patients have such terrible co-morbidities that AVFs are not the appropriate.

3) Short term use of dialysis/ ultrafiltration. Such as for someone with congestive heart failure who requires atypical treatments based upon complimenting medical therapy.

4) Terrible vascular anatomy. Sometimes it is not feasible to attempt an AVF... although, there are many talented Vascular surgeons who can usually succeed in even the most difficult cases.

5) Some patients show up at the hospitals with stage 5 CKD and need RRT and it is logistically difficult to arrange an AVF prior to discharge (these patients should have "Fistual Second")

In a perfect world, no one can argue fistula first... unfortunately, circumstances (especially within the patient population we deal with) are not always ideal.

Dr. Appell commented on March 2:

As the originator of the peripheral A-V fistula, I agree in general with your comments.

The peripheral A-V fistula is the best method for chronic vascular access. We can anticipate 10 to 20 to 30 years or more of use from an A-V fistula.

However, there are instances where an A-V fistula would not be indicated.

In patients with multiple or severe co-morbidity that may be life-threatening it would not be indicated. Other means are available for dialysis. After all, an A-V fistula requires an operative procedure.

The A-V fistula is designed for long-term use. Patients requiring short-term dialysis are best treated by central lines.

The question of closure of an A-V fistula following a successful kidney transplant would depend upon the particular patient. If the fistula is not unsightly we should consider keeping it as a backup. Fistulas are well tolerated and do not detract from the transplant.

In general, as in all good medicine, the therapy should be designed to fit the patient and not vice-versa.

Dr. Prince graciously responded that same afternoon:

Such a distinguished guest... I am honored, Dr. Appell. Thank you for your contribution to the field of Nephrology… as well as for taking the time to comment here.