Sex differences in dialysis access outcomes: a scoping review Young Hun (Minjoo) Kim, Ella Taubenfeld, Jeffrey Silpe, MD, Justin Yu, MD, Firas S. Mussa, MD, MS, Gregg S. Landis, MD, and Yana Etkin, MD Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Background • The number of patients with end-stage renal disease (ESRD) requiring hemodialysis (HD) continues to increase every year.1 • Currently, women represent 37% of new patients requiring HD, a proportion that has remained steady over the last decade.1 • The preferred method of long-term HD access is arteriovenous fistula (AVF), as it carries lower risk of infectious complications and better long-term patency as compared to tunneled catheter or arteriovenous graft (AVG).2 • Current literature suggests that women have worse HD access outcomes and fewer AVFs at the initiation of HD compared to men. • There is a paucity of literature that investigates the rationale behind these differences or describes potential ways to improve outcomes for women.
Hypothesis
Figure 1: PRISMA flow diagram for article selection
Results • The female sex is associated with worse AVF maturation rates and prolonged time to maturation.7,9,16,17,21,26,28,29,31,33,40,43 • The female sex is associated with decreased AVF long-term patency as well as increased number of procedures to achieve maturation and maintain long-term patency.10-13,15,17,25,28,35,43 • The female sex is associated with increased usage of AVG and long-term dialysis catheters but lower usage of AVF, especially for HD initiation.6,7,10,14,15,31,33,37,39,43
• We hypothesize that there are sex differences in HD access outcomes, including maturation rates, long-term patency, and AVG and catheter usage. The aims of this study are to investigate these differences, as well as the rationale behind by reviewing the current literature.
Conclusions and Future Directions • Women have significantly worse AVF maturation rates, shorter long-term patency, and increased usage of AVGs and chronic catheters compared to men. • We may need to be more aggressive in women and use smaller veins (with a minimal size of 2mm as per ESVS guidelines) in order to improve their overall maturation rates. • We also need to further research the reasoning behind these sex differences in attempt to address the root causes.
Resources
Methods • We searched relevant articles on PubMed and Embase using key search terms including: (Hemodialysis access AND women) OR (Hemodialysis access AND gender) OR (Arteriovenous fistula AND women) OR (Arteriovenous fistula AND gender) • Of the 3020 articles identified, 39 articles were deemed relevant to the purpose of this study based on the inclusion/exclusion criteria. • The process of article selection followed the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. This flow diagram is depicted in Figure 1.5 • From the selected articles, relevant narratives were organized into a data extraction table.
Figure 4: Forest plot of studies showing differences in AVG/catheter usage in women vs. men
Figure 2: Forest plot of studies demonstrating differences in AVF maturation rates in women vs. men
Figure 7: Independent CRISPR knockout of CDK4 or CDK6 does not cause dropout in most breast cancer cell lines studied.
Figure 3: Forest plot of studies showing differences in AVF long-term patency outcomes in women vs. men
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