Gender differences in vascular access in hemodialysis patients in the United States: developing strategies for improving access outcome.

BACKGROUND: Patients undergoing chronic hemodialysis (HD) require placement of permanent vascular access with the creation of an arteriovenous fistula (AVF), an arteriovenous prosthetic graft (AVG), or a tunneled central venous catheter. AVFs provide greater long-term patency, fewer complications, and lower infection rates than do either AVGs or catheters. Despite these advantages, women continue to be underrepresented among AVF patients, possibly because of concerns about smaller vascular diameters and higher rates of early primary fistula failure in female HD patients. The numerous clinical benefits of AVF suggest that a greater effort should be made to promote AVF placement in women.
OBJECTIVE: This review analyzes risk factors for AVF failure in women and describes clinical strategies to improve AVF utilization and success for female HD patients.
METHODS: English-language publications were identified through a MEDLINE database search from January 1997 to March 2007, using the search terms arteriovenous fistula, vascular access, hemodialysis, female, and gender. Reference lists of identified articles were also reviewed.
RESULTS: There are significant benefits to using AVFs instead of AVGs or catheters in HD patients: greater long-term fistula patency, superior flow rates, and fewer complications. Vascular anatomical differences between the sexes contribute to the underutilization of AVF in women. AVF placement rates can be improved if patients and staff are adequately educated and provided with the tools to facilitate AVF placement. Noninvasive preoperative screening is important to identify superior access sites in women. Intraoperative monitoring of blood flow is a reliable predictor of early radiocephalic AVF patency. Routine postoperative vascular monitoring may improve overall success with AVF, and exercise may improve vascular diameter and may be even more beneficial for women, who may have smaller preoperative veins.
CONCLUSIONS: Concerns about smaller vascular diameters and reports of higher failure rates in women may prevent nephrologists and surgeons from considering AVF for female HD patients. The numerous advantages associated with AVF suggest that a greater effort should be made to increase its utilization in women. With appropriate motivation, care, and diligence by treating clinicians, the success of AVFs in women can approach the good results typically expected in men.