Con: On cardiovascular outcomes and the arteriovenous fistula: lesser of evils

Extract

The arteriovenous fistula (AVF) was adopted in the clinical practice of dialysis in the 1960s without prospective randomized trials, simply on the basis of utility. It was widely hailed as a major improvement from the Scribner shunt, and is rightfully credited with allowing chronic hemodialysis (HD) to flourish as a modality [1]. But this history does not negate the fact that the AVF is a harmful, non-physiological anomaly, with considerable downsides. These are either not mentioned or downplayed in programs to increase fistula use [2]. Anointing any particular remedy in medicine is hazardous, in that it deters research into better alternatives.

I am not advocating that the AVF be banned, nor am I a catheter proponent. I wish to encourage a thoughtful, common sense, individualized approach to HD access; an approach that matches the access to the needs of each patient, and that takes into account the negative effects of the AVF. I am suggesting that emotion be removed from this process and replaced by cool, clinical judgment.