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Best Threshold for Diagnosis of Stenosis or Thrombosis within Six Months of Access Flow Measurement in Arteriovenous Fistulae

Marcello Tonelli^*,,, Gian S. Jhangri, David J. Hirsch^||,¶, Joanne Marryatt^¶, Paula Mossop^¶, Colleen Wile^¶ and Kailash K. Jindal^*

*Department of Medicine, University of Alberta, Edmonton, Canada; Department of Critical Care, University of Alberta, Edmonton, Canada; Institute of Health Economics, Edmonton, Canada; Department of Public Health Sciences, University of Alberta, Edmonton, Canada; ^||Department of Medicine, Dalhousie University, Halifax, Canada; and ^¶Queen Elizabeth II Health Sciences Centre, Halifax, Canada

Correspondence to Dr. Marcello Tonelli, 11-108 Clinical Sciences Building, 8440-112 Street, Edmonton, Alberta T6G 2G3, Canada. Phone: 780-407-8716; Fax: 780-407-7878; E-mail: mtonelli{at}ualberta.ca

ABSTRACT. Canadian clinical practice guidelines recommend performing angiography when access blood flow (Qa) is <500 ml/min in native vessel arteriovenous fistulae (AVF), but data on the value of Qa that best predicts stenosis are sparse. Because correction of stenosis in AVF improves patency rates, this issue seems worthy of investigation. Receiver-operating characteristic curves were constructed to examine the relationship between different threshold values of Qa and stenosis in 340 patients with AVF. Stenosis was defined by the composite outcome of access failure or angiographic stenosis occurring within 6 mo of the first Qa measurement. The Qa value was then classified as true negative, true positive, false negative, or false positive for stenosis. An additional analysis was performed in which Qa was corrected for systolic BP before assigning it to one of the four diagnostic categories. The area under the curve for the composite definition of stenosis was 0.86. Graphically, Qa thresholds of <500 and <600 ml/min had similar efficacy for detecting stenosis or access failure within 6 mo, and both seemed superior to <400 ml/min. However, the frequency of the composite definition of stenosis among AVF with Qa between 500 and 600 ml/min was only 6 (25%) of 24, as compared with 58 (76%) of 76 when Qa was <500 ml/min. This suggests that most lesions that would be found using a threshold of <600 ml/min occurred in AVF with Qa <500 ml/min and that the small gain in sensitivity associated with the <600-ml/min threshold would be outweighed by the reduced specificity compared with <500 ml/min. Correcting Qa for BP did not improve diagnostic performance or change these results, which were consistent in several sensitivity analyses. Qa measurements seemed to predict stenosis or incipient access failure equally well in groups defined by diabetic status, gender, and AVF location. In conclusion, it was found that Qa <500 ml/min seems to be the most appropriate threshold for performing angiography in patients with native vessel AVF. It is recommended that clinicians arrange angiography when Qa is <500 ml/min in AVF.

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Copyright © 2009 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673