NIHR Signal Regional anaesthesia could improve fistula function for kidney dialysis

Published on 25 July 2017

Use of regional anaesthesia when creating a fistula for vascular access may reduce the risk of failure by about 70%.

Easy access to blood vessels is important when someone needs kidney dialysis and the commonest procedure is forming of an artificial link between arteries and veins, called a fistula. Unfortunately some newly formed fistulas fail because the blood vessel is not “patent” or open wide enough to work properly.

This systematic review found four randomised controlled trials of adults having surgery to make an arteriovenous fistula for kidney dialysis. The trials compared how well the fistulas worked when they had been formed using regional anaesthesia compared with those formed using local anaesthesia.

This review suggests that surgeons, when creating fistulas for haemodialysis, should consider doing so under a regional anaesthetic. This may reduce the need for repeated surgery and reduce the time waiting to start dialysis.

Share your views on the research.

Why was this study needed?

Health Survey data suggests around 13% of people in the UK are living with chronic kidney disease and, according to the Renal Registry, in 2013 almost 24000 people in the UK received haemodialysis. 

When chronic kidney disease becomes severe, haemodialysis is one option to replace the failing kidney’s functions. One person on haemodialysis costs the NHS around £35,000 per year.

Joining an artery and vein in the forearm to create a new blood vessel called an arteriovenous fistula is the preferred way to access the bloodstream. The fistula takes around six weeks to heal. However, in some cases flow is poor and clots can block the fistula.

This review aimed to see if local anaesthetic (where a small area is numbed around the fistula) or regional anaesthetic (where a large area of the arm is numbed by an injection around the main nerves to the arm in the neck or armpit) has any bearing on the success of the fistula formation.  

What did this study do?

In this systematic review and meta-analysis, four randomised controlled trials were included with a total of 286 adults. One trial was conducted in the UK.

The trials compared the outcome of arteriovenous fistulas in participants who had local anaesthetic when their fistula was formed, to those who had a regional anaesthetic. Participants were receiving a fistula for the first time. The primary outcome was either failure or success of the fistula at follow up.

The results of this review should be interpreted with caution because the studies had varied methods of administering regional anaesthetic, and the type and dose of drugs varied between studies.

What did it find?

  • Having a regional anaesthetic reduced the risk of the fistula failing by 72%. In those who had local anaesthetic 12.6% (36/286) had failed fistulas compared to 4.1% (12/286) for those having a regional anaesthetic (odds ratio 0.28, 95% confidence interval 0.14 to 0.57). 
  • Complications of anaesthesia did not occur in one study, and were not reported in two studies.

What does current guidance say on this issue?

No relevant guidance is available on which anaesthetic to use when creating an arteriovenous fistula.

What are the implications?

These results show that different anaesthetic choices could impact the success of a fistula. A patent fistula means prompt kidney replacement therapy. Time and money are saved if a fistula doesn’t need to be recreated or revised under general anaesthesia.

However, the review is fairly small and larger trials across different institutions may be required before the size of the benefit can be precisely estimated. Nevertheless for centres that already have the skills and facilities to undertake regional anaesthesia for these procedures it may be a simple change to implement.

If further large randomised trials are undertaken, it would be useful to investigate the cost effectiveness of regional anaesthesia compared to local anaesthesia, and to include an analysis of patient reported outcomes.

Citation and Funding

Cerneviciute R, Sahebally SM, Ahmed K, et al. Regional Versus Local Anaesthesia for Haemodialysis Arteriovenous Fistula Formation: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2017;53(5):734-42.

No funding information was provided for this study.

Bibliography

Aitken E, Jackson A, Kearns R et al. Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial. Lancet 2016;388:1067e74.

British Kidney Patient Association. Chronic Kidney Disease Factsheet. Alton: British Kidney Patient Association; 2014.

Dr Richard Fluck & Dr Mick Kumwenda. Vascular Access for Haemodialysis. 5th edition 2008 – 2011. UK Renal Association; 2011.

National Clinical Guideline Centre. Chronic kidney disease (partial update). Clinical Guideline 182. London: National Institute for Health and Care Excellence; 2014.

NHS Choices. Dialysis. London: Department of Health; 2015.

NHS Choices. Chronic Kidney Disease. Department of Health; 2016.

NKF Kidney Patients UK. Transplantation cost effectiveness. Nottingham: NKF Kidney Patients UK; 2010.

Why was this study needed?

Health Survey data suggests around 13% of people in the UK are living with chronic kidney disease and, according to the Renal Registry, in 2013 almost 24000 people in the UK received haemodialysis. 

When chronic kidney disease becomes severe, haemodialysis is one option to replace the failing kidney’s functions. One person on haemodialysis costs the NHS around £35,000 per year.

Joining an artery and vein in the forearm to create a new blood vessel called an arteriovenous fistula is the preferred way to access the bloodstream. The fistula takes around six weeks to heal. However, in some cases flow is poor and clots can block the fistula.

This review aimed to see if local anaesthetic (where a small area is numbed around the fistula) or regional anaesthetic (where a large area of the arm is numbed by an injection around the main nerves to the arm in the neck or armpit) has any bearing on the success of the fistula formation.  

What did this study do?

In this systematic review and meta-analysis, four randomised controlled trials were included with a total of 286 adults. One trial was conducted in the UK.

The trials compared the outcome of arteriovenous fistulas in participants who had local anaesthetic when their fistula was formed, to those who had a regional anaesthetic. Participants were receiving a fistula for the first time. The primary outcome was either failure or success of the fistula at follow up.

The results of this review should be interpreted with caution because the studies had varied methods of administering regional anaesthetic, and the type and dose of drugs varied between studies.

What did it find?

  • Having a regional anaesthetic reduced the risk of the fistula failing by 72%. In those who had local anaesthetic 12.6% (36/286) had failed fistulas compared to 4.1% (12/286) for those having a regional anaesthetic (odds ratio 0.28, 95% confidence interval 0.14 to 0.57). 
  • Complications of anaesthesia did not occur in one study, and were not reported in two studies.

What does current guidance say on this issue?

No relevant guidance is available on which anaesthetic to use when creating an arteriovenous fistula.

What are the implications?

These results show that different anaesthetic choices could impact the success of a fistula. A patent fistula means prompt kidney replacement therapy. Time and money are saved if a fistula doesn’t need to be recreated or revised under general anaesthesia.

However, the review is fairly small and larger trials across different institutions may be required before the size of the benefit can be precisely estimated. Nevertheless for centres that already have the skills and facilities to undertake regional anaesthesia for these procedures it may be a simple change to implement.

If further large randomised trials are undertaken, it would be useful to investigate the cost effectiveness of regional anaesthesia compared to local anaesthesia, and to include an analysis of patient reported outcomes.

Citation and Funding

Cerneviciute R, Sahebally SM, Ahmed K, et al. Regional Versus Local Anaesthesia for Haemodialysis Arteriovenous Fistula Formation: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2017;53(5):734-42.

No funding information was provided for this study.

Bibliography

Aitken E, Jackson A, Kearns R et al. Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial. Lancet 2016;388:1067e74.

British Kidney Patient Association. Chronic Kidney Disease Factsheet. Alton: British Kidney Patient Association; 2014.

Dr Richard Fluck & Dr Mick Kumwenda. Vascular Access for Haemodialysis. 5th edition 2008 – 2011. UK Renal Association; 2011.

National Clinical Guideline Centre. Chronic kidney disease (partial update). Clinical Guideline 182. London: National Institute for Health and Care Excellence; 2014.

NHS Choices. Dialysis. London: Department of Health; 2015.

NHS Choices. Chronic Kidney Disease. Department of Health; 2016.

NKF Kidney Patients UK. Transplantation cost effectiveness. Nottingham: NKF Kidney Patients UK; 2010.

Regional Versus Local Anaesthesia for Haemodialysis Arteriovenous Fistula Formation: A Systematic Review and Meta-Analysis

Published on 14 March 2017

Cerneviciute, R.,Sahebally, S. M.,Ahmed, K.,Murphy, M.,Mahmood, W.,Walsh, S. R.

Eur J Vasc Endovasc Surg , 2017

BACKGROUND: Arteriovenous fistula (AVF) formation is the most common vascular access procedure for patients requiring haemodialysis. However, it is associated with high failure rates, influenced by vessel diameter and arterial inflow. Mode of anaesthesia may affect these factors, and subsequently AVF maturation rates. OBJECTIVE: To perform a systematic review and meta-analysis to assess the effect of anaesthesia type for autologous primary radiocephalic or brachiocephalic AVF creation on subsequent fistula failure rates. METHODS: The online databases of Medline, EMBASE, CINAHL, The Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and Google Scholar as well as vascular and anaesthesiology conference abstracts were searched on August 1, 2016. Randomised control trials (RCTs) that reported the effect of anaesthesia type on subsequent failure rates during autologous AVF creation were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was also carried out. RESULTS: Four RCTs (286 patients) were identified with 286 autologous AVFs. There were 48 fistula failures. Most of the studies suffered from significant methodological flaws. There was a significantly lower failure rate among patients undergoing regional (12/143) compared with local (36/143) anaesthesia (OR 0.28, 95% CI 0.14-0.57). On sensitivity analysis, having excluded the most heavily weighted study, the results remained significant (OR 0.20, 95% CI 0.05-0.75). CONCLUSIONS: The use of regional anaesthesia is associated with lower AVF failure rates when compared with local anaesthesia in patients undergoing primary forearm AVF formation for haemodialysis.

An arteriovenous fistula is usually created in the wrist or forearm. It can also be made in the upper arm. It is considered patent when a bruit is heard, the sound of turbulent blood flow in the vessel.

Expert commentary

Vascular access is the cornerstone of good dialysis. However, it is also the Achilles heel, being a frequent source of hospitalization, infection, intervention and psychological distress.

Careful pre-operative assessment, surgical technique and dialysis nursing are essential for good fistula function. This study shows that regional anaesthesia can also contribute to improved fistula outcomes. The safety profile is excellent and has minimal complications compared to local anaesthetic infiltration. Inevitably, there will be an initial cost implication but will be paid off in better dialysis and fewer interventions. Hopefully, regional anaesthesia will become standard for simple fistula surgery.

Mr Francis Calder, Lead Clinician in Vascular Access Surgery, Guy's and St Thomas' NHS Foundation Trust