Highlights
- •Among 56 patients, brachial artery diameter and velocity were smaller in women.
- •Women had fewer circulating monocytes during maturation than men.
- •Arterial inflow and the immune system drive sex differences during arteriovenous fistula maturation.
Background
Arteriovenous fistulae mature less frequently in women than in men, leading to inferior
patency and decreased fistula utilization in women. We hypothesized that both anatomic
and physiologic sex differences explain reduced maturation.
Methods
The electronic medical records of patients who had a primary arteriovenous fistula
created from 2016 to 2021 at a single center were reviewed; sample size was determined
using a power calculation. Postoperative ultrasound and laboratory tests were obtained
at least 4 weeks after fistula creation. Primary unassisted fistula maturation was
determined up to 4 years postprocedure.
Results
A total of 28 women and 28 men with a brachial-cephalic fistula were analyzed. The
inflow brachial artery diameter was smaller in women than in men, both preoperatively
(4.2 ± 0.9 vs. 4.9 ± 1.0 mm, P = 0.008) and postoperatively (4.8 ± 0.8 vs. 5.3 ± 0.9 mm, P = 0.039). Despite similar preoperative brachial artery peak systolic velocity, women
had significantly lower postoperative arterial velocity (P = 0.027). Fistula flow was reduced in women, particularly in the midhumerus (747.0 ± 570.4
vs. 1,117.1 ± 471.3 cc/min, P = 0.003). Percentages of neutrophils and lymphocytes were similar among women and
men 6 weeks after fistula creation. However, women had reduced monocytes (8.5 ± 2.0
vs. 10.0 ± 2.6%, P = 0.0168). Among 28 men, 24 of 28 (85.7%) achieved unassisted maturation, whereas
only 15 of 28 (53.6%) women had fistulae that matured without intervention. Secondary
analysis using logistic regression suggested that postoperative arterial diameter
was associated with maturation in men, while postoperative monocyte percentage was
associated with maturation in women.
Conclusions
Sex differences during arteriovenous fistula maturation are present in arterial diameter
and velocity, suggesting that both anatomic and physiologic differences in arterial
inflow contribute to sex differences in fistula maturation. In men, postoperative
arterial diameter is correlated with maturation, whereas in women, the significantly
lower proportion of circulating monocytes suggests a role for the immune response
in fistula maturation.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Annals of Vascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Vascular access in hemodialysis: issues, management, and emerging concepts.Cardiol Clin. 2005; 23: 249-273
- 'United States renal data system 2011 annual data report: atlas of chronic kidney disease & end-stage renal disease in the United States.Am J Kidney Dis. 2012; 59 (e1-420): A7
- Vascular access survival and incidence of revisions: a comparison of prosthetic grafts, simple autogenous fistulas, and venous transposition fistulas from the United States Renal Data System Dialysis Morbidity and Mortality Study.J Vasc Surg. 2001; 34: 694-700
- Superiority of autogenous arteriovenous hemodialysis access: maintenance of function with fewer secondary interventions.Ann Vasc Surg. 2004; 18: 66-73
- Biology of arteriovenous fistula failure.J Nephrol. 2007; 20: 150-163
- Future research directions to improve fistula maturation and reduce access failure.Semin Vasc Surg. 2016; 29: 153-171
- The natural history of autologous fistulas as first-time dialysis access in the KDOQI era.J Vasc Surg. 2008; 47: 415-421
- Failure of arteriovenous fistula maturation: an unintended consequence of exceeding dialysis outcome quality Initiative guidelines for hemodialysis access.J Vasc Surg. 2003; 38: 439-445
- Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions.Kidney Int. 2002; 62: 1109-1124
- Gender differences in outcomes of arteriovenous fistulas in hemodialysis patients.Kidney Int. 2003; 63: 346-352
- Disparities in fistula maturation persist despite preoperative vascular mapping.Clin J Am Soc Nephrol. 2008; 3: 437-441
- Prediction of arteriovenous fistula clinical maturation from postoperative ultrasound measurements: findings from the hemodialysis fistula maturation study.J Am Soc Nephrol. 2018; 29: 2735-2744
- Vein diameter is the major predictor of fistula maturation.J Vasc Surg. 2009; 49: 1499-1504
- Early predictors of arteriovenous fistula maturation: a novel perspective on an enduring problem.J Am Soc Nephrol. 2020; 31: 1617-1627
- Is intra-operative blood flow predictive for early failure of radiocephalic arteriovenous fistula?.Nephrol Dial Transplant. 2009; 25: 862-867
- Venous access: women are equal.Am J Kidney Dis. 2003; 41: 429-432
- Diameter criteria have limited value for prediction of functional dialysis use of arteriovenous fistulas.Eur J Vasc Endovasc Surg. 2018; 56: 572-581
- Preoperative sonographic radial artery evaluation and correlation with subsequent radiocephalic fistula outcome.J Ultrasound Med. 2004; 23: 161-168
- Impact of preoperative arterial and venous diameter on achievement of the adequate blood flow in arteriovenous fistula for hemodialysis.Ther Apher Dial. 2020; 25: 273-281
- Dialysis fistulae patency and preoperative diameter ultrasound measurements.Eur J Vasc Endovasc Surg. 2007; 33: 467-471
- Morphologic and functional vessels characteristics assessed by ultrasonography for prediction of radiocephalic fistula maturation.J Vasc Access. 2013; 14: 356-363
- Sex differences in immune responses.Nat Rev Immunol. 2016; 16: 626-638
- Distinct subsets of T cells and macrophages impact venous remodeling during arteriovenous fistula maturation.JVS Vasc Sci. 2020; 1: 207-218
- Sex differences in inflammation during venous remodeling of arteriovenous fistulae.Front Cardiovasc Med. 2021; 8: 715114
- Preoperative ultrasonographic mapping of blood vessels before arteriovenous fistula construction in elderly patients with end-stage renal disease.Ther Apher Dial. 2009; 13: 334-339
- Natural vascular remodelling after arteriovenous fistula creation in dialysis patients with and without previous ipsilateral vascular access.Eur J Vasc Endovasc Surg. 2020; 59: 277-287
- A class of K-sample tests for comparing the cumulative incidence of a competing risk.Ann Stat. 1988; 16: 1141-1154
- High pulse pressure predicts primary arteriovenous fistula failure within 1 year.J Vasc Access. 2022; (11297298211054797)
- Inhibition of T-cells by cyclosporine A reduces macrophage accumulation to regulate venous adaptive remodeling and increase arteriovenous fistula maturation.Arterioscler Thromb Vasc Biol. 2021; 41: e160-e174
- Sex differences in age trajectories of physiological dysregulation: inflammation, metabolic syndrome, and allostatic load.J Gerontol A Biol Sci Med Sci. 2011; 66: 493-500
- The TLR-mediated response of plasmacytoid dendritic cells is positively regulated by estradiol in vivo through cell-intrinsic estrogen receptor α signaling.Blood. 2012; 119: 454-464
- Progesterone favors the development of human T helper cells producing Th2-type cytokines and promotes both IL-4 production and membrane CD30 expression in established Th1 cell clones.J Immunol. 1995; 155: 128-133
- Sexual dimorphism in phagocytic activity of wall lizard.Gen Comp Endocrinol. 1999; 116: 291-298
Article info
Publication history
Published online: February 20, 2023
Accepted:
January 28,
2023
Received:
December 6,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Conflict of interest: The Authors declare that there is no conflict of interest.
Funding sources: This work was supported by the US National Institutes of Health grants R01-HL144476 and R01-HL162580.
Identification
Copyright
Published by Elsevier Inc.
