Patency of arteriovenous fistulas in hemodialysis in French Guiana: influence of vascular flow, climate and clinical factors.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Nephrol . 2026 Feb 24;27:202. doi: 10.1186/s12882-026-04857-6 Search in PMC Search in PubMed View in NLM Catalog Add to search Patency of arteriovenous fistulas in hemodialysis in French Guiana: influence of vascular flow, climate and clinical factors Dévi Rita Rochemont Dévi Rita Rochemont 1 REIN Registry, CHU de Guyane, CHU Guyane, ISPA, 3 rue Alexis Blaise, Cayenne Cedex, Cayenne, BP 6006 French Guiana 4 INSERM CIC 1424 Guyane Amazonie, CHU de Guyane, Cayenne, French Guiana Find articles by Dévi Rita Rochemont 1, 4, ✉ , Tanguy Fortune Gbaguidi Tanguy Fortune Gbaguidi 2 Nephrology, CHU de Guyane, Cayenne, French Guiana Find articles by Tanguy Fortune Gbaguidi 2 , Modibe Sidibe Modibe Sidibe 2 Nephrology, CHU de Guyane, Cayenne, French Guiana Find articles by Modibe Sidibe 2 , Malika Belgrine Malika Belgrine 2 Nephrology, CHU de Guyane, Cayenne, French Guiana Find articles by Malika Belgrine 2 , Timote Davodoun Timote Davodoun 2 Nephrology, CHU de Guyane, Cayenne, French Guiana Find articles by Timote Davodoun 2 , Khaly Mamadou Sow Khaly Mamadou Sow 1 REIN Registry, CHU de Guyane, CHU Guyane, ISPA, 3 rue Alexis Blaise, Cayenne Cedex, Cayenne, BP 6006 French Guiana Find articles by Khaly Mamadou Sow 1 , Marie-Paule Joly Marie-Paule Joly 3 Cardiology, CHU de Guyane, Cayenne, French Guiana Find articles by Marie-Paule Joly 3 , Mathieu Nacher Mathieu Nacher 1 REIN Registry, CHU de Guyane, CHU Guyane, ISPA, 3 rue Alexis Blaise, Cayenne Cedex, Cayenne, BP 6006 French Guiana 4 INSERM CIC 1424 Guyane Amazonie, CHU de Guyane, Cayenne, French Guiana Find articles by Mathieu Nacher 1, 4 Author information Article notes Copyright and License information 1 REIN Registry, CHU de Guyane, CHU Guyane, ISPA, 3 rue Alexis Blaise, Cayenne Cedex, Cayenne, BP 6006 French Guiana 2 Nephrology, CHU de Guyane, Cayenne, French Guiana 3 Cardiology, CHU de Guyane, Cayenne, French Guiana 4 INSERM CIC 1424 Guyane Amazonie, CHU de Guyane, Cayenne, French Guiana ✉ Corresponding author. Received 2025 Nov 25; Accepted 2026 Feb 18; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13037059  PMID: 41735861 Abstract Introduction Arteriovenous fistula (AVF) is the preferred access for hemodialysis. Achieving one-year patency is crucial to avoid dependence on central venous catheters, which carry significant risks of infection and thrombosis. In French Guiana, a territory marked by precariousness, isolation, and a tropical climate, local determinants of patency are poorly documented. This study aims to evaluate AVF patency at 6 weeks and one year and to identify associated factors. Methods This is a single-center retrospective study including all AVFs created at the Cayenne Hospital Center between 2018 and 2022. Demographic data, comorbidities, vascular parameters, technical characteristics, and season were analyzed. Associations were studied using univariate and multivariate logistic regressions with a multilevel model. The primary endpoint was AVF patency at 6 weeks and 1 year. Results Among 176 patients, 226 AVFs were created, 92.5% of which were autologous. Patency at one year was 73.7%. Obesity (Body Mass Index ≥ 30) was associated with reduced patency at one year (OR = 0.46; 95% CI [0.24–0.85], p = 0.014) but not at 6 weeks while active smoking reduced patency at one year (OR = 0.34; [0.13–0.89], p = 0.029) but not at 6 weeks. Each previous AVF also reduced the probability of patency (OR = 0.45; [0.27–0.75], p = 0.002 at 6 weeks; OR = 0.54; [0.35–0.84], p = 0.006 at one year). Conversely, a higher mean initial arterial flow significantly improved patency (OR = 3.31; [1.22–8.92], p = 0.018); high flow had an even more pronounced effect (OR = 6.32; [1.63–24.6], p = 0.008); a larger radial diameter was also associated with better outcomes (OR = 2.42; [1.45–4.05], p = 0.001). A season × flow interaction suggested increased vulnerability of AVFs at low flow during the wet season (OR = 0.15; [0.02–1.04], p = 0.05). Conclusions In French Guiana, AVF patency at one year is primarily determined by vascular parameters (arterial flow and diameter). Modifiable risk factors including obesity and active smoking significantly reduce patency, while multiple previous AVF attempts predict worse outcomes. Exploratory analysis suggests possible seasonal vulnerability in low-flow fistulas, requiring prospective vascular assessment, risk factor optimization, and targeted protocols. Study registration Not applicable. This is a retrospective observational cohort study. Trial registration is not required for observational studies according to ICMJE and BMC guidelines. The study was not registered prospectively. Keywords: Arteriovenous fistula, Dialysis, Patency, Health inequalities, Tropical climate Introduction Arteriovenous fistulas (AVFs) remain the vascular access of choice for hemodialysis due to their superior longevity and low complication rate compared to central venous catheters and prosthetic grafts [ 1 , 2 ]. However, achieving and maintaining AVF patency represents a major clinical challenge. AVF failure necessitates reliance on central venous catheters, which are associated with increased risks of infection, thrombosis, cardiovascular complications and mortality, as well as substantially higher treatment costs [ 2 ]. The success of an AVF extends beyond its surgical creation, depending critically on adequate maturation and sustained long-term function. This durability is determined by a complex interaction between patient factors (diabetes, hypertension, smoking, obesity) vascular characteristics (vessel diameter, arterial flow) and technical considerations [ 1 , 2 ]. International guidelines, including those the Kidney Disease Outcomes Quality Initiative (KDOQI) recommend assessment of AVF maturation at two standardized timepoints: six weeks post-creation to detect primary maturation failures, and one year to evaluate long-term durability [ 2 , 3 ]. Systematic surveillance using blood flow rate measurements has demonstrated value in reducing thrombosis and improving patency [ 4 ], while, pre-existing arterial pathology, beyond simple dimensional measurements plays a crucial role in determining outcomes [ 5 ]. Although AVF outcomes have been extensively studied in temperate regions, important data also exist from tropical and subtropical settings including Singapore, Malaysia, and Brazil [ 6 – 10 ] Nevertheless, many geographical contexts remain underrepresented in the vascular access literature. French Guiana, a French overseas territory located near the equator in South America, presents a unique opportunity to examine AVF outcomes in an environment characterized by substantial health inequalities and barriers to care. With a multi-ethnic, multicultural population of approximately 290, 000, French Guiana experiences massive immigration driven by the search for better socioeconomic conditions. However, over half the population lives below the national poverty line and faces significant healthcare disparities [ 11 , 12 ]. Previous studies from our group have documented that patients in French Guiana develop end-stage renal disease at a younger ages and often present in emergency situations, reflecting social precariousness and barriers to preventive nephrology care [ 13 , 14 ]. Geographical isolation compounds these challenges: one-fifth of the population lives more than 30 min from emergency services, and interior residents often require hours of travel by car or canoe to reach the nearest hospital [ 15 ]. These geographical barriers, combined with poverty and limited health literacy in certain populations [ 16 ], make regular follow-up and rapid treatment of complications particularly difficult. The establishment of specialized access services such as the Permanence d’Accès aux Soins de Santé (PASS) [ 17 ], reflects institutional recognition of these challenge. French Guiana’s Amazonian climate, characterized by alternating wet and dry seasons, high heat, and humidity, may theoretically influence AVF outcomes through several indirect mechanisms. Excessive sweating and dermatitis may increase risks of skin lesions and puncture-site infections [ 18 ], while vascular access-related infections, can lead to AVF loss and represent the second leading cause of mortality in hemodialysis patients [ 19 ]. In addition, heat-induced dehydration may promote hemoconcentration and increased blood viscosity, well-established mechanisms that elevate thrombosis risk [ 13 – 15 ]. However, despite these theoretical concerns, no previous studies have examined seasonal or climatic effects on AVF patency in tropical settings. Given the scarcity of specialized surgical resources, geographical isolation, socioeconomic barriers, high prevalence of vascular risk factors, and unique climatic conditions, we hypothesized that AVF durability in French Guiana might be compromised compared to mainland France, making each vascular access creation particularly valuable. This single-center retrospective cohort study therefore aimed to evaluate AVF patency at 6 weeks and 1 year at the Cayenne Hospital Center, and to identify clinical, vascular and environmental factors associated with patency in this underserved, geographically isolated, tropical setting. Methods Study type This was a single-center retrospective study including all adult patients (≥ 18 years) who underwent AVF creation between January 1, 2018, and December 31, 2022, at Cayenne Hospital Data were extracted from the REIN (Réseau Epidémiologie et Information en Néphrologie) national registry, supplemented by review of electronic medical records at Cayenne Hospital Center. Classification of arteriovenous fistulas and assessment of their patency Fistulas were classified according to their topography and nature (autologous or prosthetic) in accordance with international standards: (1) Radiocephalic (RC) anastomosis between the radial artery and cephalic vein at the wrist level (snuffbox or forearm); (2) Brachiocephalic (BC) Anastomosis between the brachial artery and cephalic vein at or near the antecubital fossa; (3) Brachiobasilic (BB) Anastomosis between the brachial artery and basilic vein. Transposition status was not systematically recorded; (4) Prosthetic/synthetic grafts, Arteriovenous grafts using synthetic material (PTFE)., Given the distinct patency profiles of autologous versus prosthetics access, we performed a sensitivity analysis excluding prosthetic grafts, which confirmed the robustness of our findings for autologous AVFs. Arterial flow was classified into three categories (low: less than 650 mL/min, medium: 650 to 1250 mL/min, high: greater than 1250 mL/min) according to quantiles. AVFs are sometimes defined as > 1500–2000 mL/min or > 20–30% of cardiac output when associated with hemodynamic complications. In our cohort, no high-output cardiac failure or steal syndrome necessitating AVF ligation was observed, suggesting that our “high flow” category represents adequate flow for maturation rather than pathological hyperflow. Our thresholds should be interpreted in the context of optimal flow for AVF success rather than as markers of flow-related complications.Primary patency, defined as maintaining a functional AVF without abandonment or thrombosis, was the primary endpoint. This definition aligns with KDOQI guidelines for functional primary patency. It was assessed at two time points: at 6 weeks (the time recommended by KDOQI guidelines for assessing primary maturation and early detection of technical failures) and one year (a standard indicator of vascular access durability widely used in the literature for cross-study comparison. Preoperative vascular assessment and institutional workflow All AVFs were created at Cayenne Hospital Center, the referral center for vascular access surgery in French Guiana. Vascular access planning followed a multidisciplinary approach with weekly meetings involving nephrologists, vascular surgeons, and vascular physicians. The decision between AVF creation versus tunneled catheter placement was based on clinical assessment, life expectancy, vascular anatomy on Doppler ultrasound mapping, and patient preferences when possible. Patients with severe arterial disease, inadequate veins, very limited life expectancy, or requiring immediate dialysis were preferentially assigned to catheter placement. Our institution followed a “distal-first” approach consistent with KDOQI guidelines, prioritizing autologous fistulas with prosthetic grafts reserved as second-line options. Interventional radiology services were available on-site for angioplasty and thrombectomy; procedures performed to maintain fistula function were classified as interventions, with fistulas remaining functional after such procedures counted as having primary assisted patency in our analysis. All patients underwent preoperative Doppler ultrasound mapping to assess arterial and venous anatomy. Mapping was performed as part of routine clinical care without a standardized research protocol. Timing of initial arterial flow measurement: Initial arterial flow and arterial diameter measurements were obtained by Doppler ultrasound at the time of preoperative vascular assessment, prior to AVF creation. For patients already on dialysis, measurements were taken immediately before the surgical procedure. This timing ensures that the reported flow values represent baseline vascular characteristics rather than post-operative measurements, which is particularly important for interpreting results in AVFs that failed by 6 weeks. Variables collected Independent variables included Demographic characteristics (age, sex), comorbidities (diabetes, hypertension, smoking, obesity, cardiovascular and infectious history) and vascular parameters (initial arterial flow, initial brachial and radial artery diameter) collected at the time of AVF creation, regardless of whether the patient was already on dialysis. Technical characteristics (type of AVF, autologous vs. prosthetic, anatomical site) and season (dry vs. rainy) at the time of AVF creation were collected. The number of AVFs per patient was coded as a continuous variable representing the number of vascular accesses created for the same patient between 2018 and 2022. In terms of sensitivity, we tested a categorization (1 vs. ≥2) to assess possible non-linearity. A comorbidity score was also created as a potential explanatory variable. Statistical analysis Patient and fistula characteristics were described using percentages for qualitative variables and means (+/- SD) for quantitative variables. Binary groups (permeable/non-permeable) were compared using Chi-square tests for qualitative variables and the Wilcoxon-Mann-Whitney test for quantitative variables. An initial univariate analysis was performed to assess the association between each independent variable and AVF patency. Variables with a p-value < 0.2 in univariate analysis or clinically relevant variables were selected for the multivariate model. The variables of sex and age were included from the outset, regardless of their level of significance. Given that several AVFs could belong to the same patient, we used a random effects logistic model (multilevel model) with the patient at level 2 to take into account intra-patient correlation. A multivariate logistic regression analysis was performed to identify factors independently associated with patency, using a stepwise downward selection strategy to obtain the most parsimonious model. Clinically relevant interactions (age × sex, season × flow) were tested based on a priori biological plausibility. Some reported odds ratios show wide confidence intervals, reflecting sparse data in certain subgroups (particularly high-flow fistulas, where no failures were observed at 6 weeks, resulting in perfect prediction). These findings should be interpreted with appropriate caution pending validation in larger cohorts. The results are presented as odds ratios (OR) with their 95% confidence intervals. A p-value < 0.05 was considered statistically significant. All results are adjusted for patient sex and age unless otherwise stated. Potential collinearity between arterial flow and arterial diameters was assessed by the variance inflation factor (VIF) after multiple linear regression. All analyses were performed using Stata 19 software. Follow-up completeness All patients included in the analysis had sufficient follow-up to be assessed at the 6-week endpoint. For the 1-year patency analysis, patients were censored if they died, received a kidney transplant, or were transferred to another facility before reaching 12 months. The one-year patency rate of 73.7% reflects the proportion of AVFs that remained patent among those with complete follow-up to 12 months. Results Among 176 patients, 226 AVFs were created, including 114 first AVFs. Of the 226 AVFs created, 92.48% were standard autologous fistulas (radial-cephalic, brachio-cephalic, or brachio-basilic). Primary maturation failure (defined as AVFs that never matured sufficiently for successful hemodialysis use by 6 weeks) was observed in 26.2% of cases, while 73.7% remained patent at one year. The mean age of patients at the time of fistula creation was 59.3 ± 14.8 years; the male-to-female ratio was 1.4; 52.8% of patients were diabetic. The characteristic based on patency are detailed on Table 1 . Table 1. Comparison of patient characteristics based on patency Variable Total cohort Patency at 6 weeks p Patency at 1 year p N = 226 AVF Yes No Yes No Age, years (mean ± SD) 59.3 ± 14.84 ans 59.28 ± 15.29 60.29 ± 12.78 0.71 58.63 ± 15.49 60.59 ± 13.11 0.39 Male, n(%) 105(60) 22(57.8) 0.81 94(58) 37(64) 0.4 BMI, kg/m² (mean ± SD) 25.79 ± 6.29 25.42 ± 6.01 25.84 ± 5.72 0.73 25.54 ± 6.15 26.83 ± 6.97 0.23 Obesity (BMI > = 30), (%) 30.97% 29.39% 36.84% 0.35 26.99% 44.83 0.012 Diabetes (%) 52.82% 51.23% 60.61% 0.33 52.56% 55.32% 0.74 Stroke Too much data missing Heart failure 18.36% 17.39% 24.24% 0.37 18.06% 19.15% 0.87 Lower limb arterial disease 15.79% 13.49% 21.21% 0.26 15.92% 14.89% 0.87 Coronary insufficiency 9.57% 10.43% 3.03% 0.18 10.83% 21.28% 0.065 Sleep apnea syndrome 8.25% 6.83% 15.63% 0.099 8.39% 8.70% 0.947 Myocardial infarction 5.26% 4.29% 6.06% 0.658 4.46% 4.26% 0.95 HIV 8.61% 7.36% 12.12% 0.36 7.64% 12.77% 0.28 HBV 2.39% 1.84% 6.06% 0.161 2.55% 2.13% 0.87 HCV 0.48% 0.62% 0.00% 0.65 0.64% 0.00% 0.586 Tobacco (%) Smoker 11.11% 9.52% 16.67% 0.51 8.45% 20.93% 0.076 Tobacco (%) Ex-smoker 14.26 15.65% 13.33% 0.51 14.79% 13.95% 0.076 Type of fistula (%of Autologous) 92.48% 93.71% 89.47% 0.354 93.87% 91.38 0.518 Initial arterial flow (mL/min). mean ± SD) 966.76 ± 490.48 1004.67 ± 474.52 258.13 ± 351.71 < 0.001 1015.16 ± 460.67 676.35 ± 568.95 0.001 Radial artery diameter (mm. mean ± SD) 2.88 ± 0.95 2.99 ± 0.97 2.32 ± 0.63 0.0011 3.01 ± 0.96 2.46 ± 0.78 0.0011 Brachial artery diameter (mm. mean ± SD) 5.45 ± 1.07 5.61 ± 1.03 4.48 ± 0.89 < 0.001 5.56 ± 1.04 5.08 ± 1.05 0.009 Open in a new tab Obesity (Body mass index (BMI) > 30) was identified as a significant risk factor for AVF failure at one year. Obese patients had a 51% lower probability of patency at one year compared to non-obese patients (OR = 0.46; 95% CI [0.24–0.85]; p = 0.014). Regarding patency at 6 weeks, no statistically significant association was demonstrated in obese patients in our sample. Ten percent of patients were current smokers and 13.70% were former smokers. The probability of AVF patency at one year in smokers was reduced by 66% compared to non-smokers (OR = 0.342, [0.13–0.89], p = 0.029). However, no significance was demonstrated for patency at 6 weeks in current smokers (OR = 0.53, [0.17–1.64], p = 0.274). For ex-smokers, there was no significant difference at either 6 weeks (OR = 1.098, [0.34–3.50], p = 0.875) or 1 year (OR = 0.899, [0.33–2.44], p = 0.834). Having had multiple AVFs created between 2018 and 2022 for the same patient was a risk factor for failure of new creations. Each additional AVF reduced the probability of patency. At 6 weeks, the OR was 0.45 [0.27–0.75], p = 0.002, and at 1 year, the OR was 0.54 [0.35–0.84], p = 0.006. The non-linearity of the effect was confirmed with an OR of 0.28 [0.13–0.58], p = 0.001 at 6 weeks and an OR = 0.43 [0.23–0.79], p = 0.007 at 1 year. The decrease in patency was more pronounced in patients who had already had several AVF. Regardless of whether the model was simple or multivariate, medium and high mean arterial flow was associated with better patency compared to low flow at both 6 weeks and 1 year. At 6 weeks, mean arterial flow was associated with better patency compared with low flow (OR = 12.77 [1.43–114.3], p = 0.023) in a multivariate model adjusted for sex and age. High-flow fistulas perfectly predicted patency (no failures observed), which explains why no OR could be calculated in the multivariate model. At one year, medium flow (OR = 3.31 [1.22–8.92], p = 0.018) and high flow (OR = 6.32 [1.63–24.6], p = 0.008) remained significantly associated with better patency (Fig. 1 ). Fig. 1. Open in a new tab Probability of patency as a function of flow rate A larger arterial diameter was also associated with better early patency (radial: OR = 3.09 [1.52–6.28], p = 0.002; brachial: OR = 3.62 [1.80–4.76], p < 0.001), and this association persisted at one year (radial: OR = 2.42 [1.45–4.05], p = 0.001; brachial: OR = 1.79 [1.21–2.63], p = 0.003) (Figs. 2 and 3 ). Fig. 2. Open in a new tab Probability of patency as a function of arterial diameter (at 6 weeks) Fig. 3. Open in a new tab Probability of patency as a function of arterial diameter (at 1 year) The correlation between flow and diameters was tested. It was weak between arterial flow and radial arterial diameter ( r = 0.13 p = 0.039) and moderate between arterial flow and brachial diameter ( r = 0.38 p < 0.001), as well as between radial diameter and brachial diameter ( r = 0.46 p < 0.001). Analysis of collinearity using the variance inflation factor (VIF = 1.18) confirmed the absence of problematic redundancy between these variables. No significant association was found between comorbidities (vascular or infectious (HIV, HCV, HBV)) and patency, even after adjustment. A comorbidity score was also tested. with inconclusive results. The rainy or dry season at the time of creation of the arteriovenous fistula was not significantly associated with patency at either 6 weeks (OR = 1.15 [0.57–2.32]; p = 0.703) or one year (OR = 1.52 [0.83–2.79]; p = 0.174), when considered in isolation. However, analysis of interactions between season and continuous flow revealed a more complex trend. We observed that the effect of season appeared to be related to initial arterial flow: statistical analysis showed that in cases of low arterial flow, the probability of patency at one year is 6.86 times higher in the dry season than in the rainy season when flow is added, (OR: 6.86; [0.96–48.96] p = 0.05). Sensitivity analysis, autologous AVFs only: Given the distinct patency characteristics of prosthetic grafts, we performed a sensitivity analysis restricted to autologous AVFs only ( N = 209, 92.5% of total). The main findings remained consistent with the primary analysis: At one year, the associations with obesity (OR = 0.41 [0.21–0.79] p = 0.008), smoking (OR = 0.3 [0.10–0.87] p = 0.026), medium arterial flow (OR = 3.56 [1.27–9.97] p = 0.016), high arterial flow (OR = 5.73 [1.47–22.3] p = 0.012), radial arterial diameter (OR = 2.32 [1.39–3.87] p = 0.001) and brachial arterial flow (OR = 1.7 {1.15–2.52] p = 0.008] remained statistically significant and in the same direction, confirming the robustness of our findings for autologous vascular access. Discussion Patency in our study was assessed at two time points: at 6 weeks, the time recommended by the KDOQI guidelines for assessing primary maturation and early detection of technical failures. and at 1 year, the threshold commonly used in the literature as a standard indicator of vascular access durability. By choosing this time frame, the study aligns with international methodological standards, allowing for a direct and valid comparison of the Cayenne cohort’s results with those of the reference cohorts. Our results show a one-year AVF patency rate of 73.7%. This result is consistent with those observed in the literature, which typically range from 60% to 80% depending on patient characteristics, surgical technique, and follow-up protocols [ 9 , 20 ]. Our rate falls within this range despite the challenges of geographical isolation and socioeconomic barriers in French Guiana, demonstrating a good level of performance. Anatomical and hemodynamic factors This study highlights the central role of initial vascular characteristics. Arterial flow proved to be a robust predictor of patency, with a clearer association when the variable was categorized into flow classes (low, medium, high), suggesting a threshold effect rather than a strictly linear relationship. These results are consistent with several recent studies that have shown that immediate postoperative flow velocity increase strongly predicted AVF maturation, highlighting the importance of flow from the earliest stages [ 21 ] and that flow measurements from the first postoperative week are highly predictive of primary patency, corroborating the value of early monitoring [ 22 ]. Furthermore, the importance of blood flow as a predictive factor is consistent with the results of studies that have proposed a weight-based approach to determining an optimal flow threshold predictive of functional patency [ 23 ]. In addition, a randomized controlled trial showed that flow monitoring significantly reduced the risk of thrombosis and improved long-term patency, which could justify intensified hemodynamic monitoring in our context [ 24 ]. Furthermore, Roca-Tey et al. demonstrated the value of blood flow rate surveillance using the Delta-H method detecting vascular access stenosis over five years of follow-up, reinforcing the importance of systemic flow monitoring [ 4 ]. The importance of arterial diameter in the success of AVFs at one year has also been highlighted. Studies confirm that larger arterial diameters are associated with better patency and emphasize the predictive value of Doppler parameters, particularly vessel size. on AVF maturation [ 25 ]. The importance of pre-existing arterial pathology has also been highlighted in the literature. Roca-Tey et al. showed that histological assessment of radial artery pathology significantly impacts the maturation, function, and patency of radiocephalic fistulas, suggesting that vascular quality—beyond simple dimensional measurements—plays a crucial role in AVF outcomes [ 5 ]. Although arterial diameter is a major determinant of blood flow, the correlation observed between these two parameters was only weak to moderate. The absence of collinearity (VIF < 2) confirms that flow and arterial diameters remain independently associated with AVF patency, suggesting that they reflect complementary mechanisms in the maturation and maintenance of vascular access. In our cohort. nearly 90% of the fistulas created were autologous. mainly radio-cephalic. brachio-cephalic, or brachio-basilic. This profile is consistent with current recommendations favoring autologous AVFs for their longer longevity and lower complication rates compared to prosthetic AVFs. Our findings regarding the impact of anatomical parameters on patency therefore apply mainly to autologous AVFs, as do studies showing that intraoperative flow rates significantly influenced the outcome of autologous AVFs [ 26 – 28 ]. The results of our study are consistent with those of Liu et al., 10-year follow-up, which showed that initial vascular characteristics rather than comorbidities alone as the main determinants of long-term AVF patency [ 29 ]. While direct comparison of our 1-year outcomes with their 10-year data is not appropriate, the underlying principle (that baseline vascular parameters are paramount) is reinforced across different follow-up durations. Finally, it is important to note that no cases of high-output cardiac failure or complications related to hyperflow (defined as excessive AVF flow leading to cardiac strain, typically > 2000 mL/mi or > 20% of cardiac output, manifesting as dyspnea, edema, or increased cardiac output) were reported in our cohort, and no AVF ligation was necessary for this reason. These data are reassuring, as hyperflow is a feared complication that can compromise AVF survival, particularly in patients with pre-existing heart disease [ 30 , 31 ]. The absence of hyperflow complications in our “high flow” category (> 1250 ml/min) suggests that this threshold represents optimal flow for maturation and long-term patency rather than pathological excess. Patient-related factors Certain patient-related factors were found to be significant. We observed that obesity (BMI > 30) was associated with a significant decrease in the probability of patency at one year (54% reduction, OR = 0.46 [0.24–0.85], p = 0.014). This unfavorable association of high BMI is consistent with a recent meta-analysis by Lee et al., concluding that obesity compromises AVF maturation and reduces primary patency rates with hazard ratios ranging from 1.5 to 2.9 for AVF failure [ 32 ], It was noteworthy that obesity was not significantly associated with early failure at 6 weeks, (OR: 0.7; 95% CI [0.34–1.50]; p = 0.379), suggesting that its deleterious effect manifests during the post-maturation maintenance phase rather than during initial maturation. This temporal pattern may reflect several mechanisms: (1) difficulties with consistent cannulation in obese patients due to deeper vessel location and excess subcutaneous tissue, leading to repeated traumatic punctures that promote stenosis and thrombosis over time [ 33 – 35 ]; (2) greater hemodynamic stress on the access due to higher cardiac output requirements in obesity [ 36 ]; and (3) chronic low-grade inflammation and endothelial dysfunction associated with obesity that progressively impairs vascular health. These factors likely compound over months, explaining why the effect becomes apparent at 1 year but not at 6 weeks [ 37 , 38 ]. In addition, our analysis revealed a strong link between active smoking and an increased risk of patency failure at one year. The deleterious impact of tobacco on the vascular system is well documented in the literature. It promotes vasoconstriction. impairs endothelial function (particularly by reducing the bioavailability of nitric oxide and increasing inflammation and oxidative stress), and accelerates atherogenesis and thrombosis [ 37 , 39 ]. The direct effect on AVFs is not documented, but this mechanism could also apply to vascular access for hemodialysis, especially since several studies have shown that tobacco reduces primary and secondary fistula patency [ 9 , 37 , 40 , 41 ]. These data support our findings that active smokers had a 66% reduction in the probability of patency at one year. However, we did not observe a significant impact for former smokers, which could suggest partial or complete reversibility of this risk after smoking cessation. The study also highlighted another important risk factor. Each additional attempt to create a VAF in the same patient significantly reduced the probability of subsequent success, both at 6 weeks and at one year. This finding is relevant because it suggests that patients requiring successive VAF creations may have poorer quality venous capital or less favorable anatomical characteristics (fibrosis, previous lesions). Studies have shown that histological changes in the vein (hyperplasia, collagen accumulation, loss of distensibility) are frequently in dialysis patients and hinder the maturation of subsequent fistulas [ 42 , 43 ]. Unlike other studies, which reported a significant impact of diabetes on AVF patency in dialysis patients, our study did not find a clear link between classic comorbidities (such as diabetes or a history of vascular or infectious disease) and patency at one year [ 44 ]. This reinforces the idea that, in our context, local factors such as surgical technique, anatomical specificities of the vessels, and the organization of care may play a more important role than systemic comorbidities. However, selection bias cannot be ruled out: patients for whom major vascular difficulties were anticipated may have been preferentially referred for tunneled venous catheter placement rather than AVF creation. Between 2018 and 2022, the proportion of dialysis patients with a tunneled catheter was 23%, which may have limited the representation of the most unfavorable profiles in the sample analyzed. Socioeconomic context and health research Socioeconomic Context and Health Inequalities Research French Guiana presents a unique socioeconomic and geographic context. Our research group has previously documented substantial health inequalities in end-stage renal disease (ESRD) in French Guiana, including younger age at dialysis initiation, high prevalence of emergency starts, and poor access to preventive nephrology care among vulnerable populations [ 13 , 14 ]. These earlier studies established that poverty, geographical isolation, immigration status, and barriers to healthcare access profoundly influence kidney disease progression in this setting. The present study builds on this foundation by examining vascular access outcomes within this vulnerable population. While we collected clinical and vascular data, we did not systematically capture individual-level socioeconomic indicators (educational attainment, household income, precise distance from hospital, housing stability) in this retrospective analysis. However, the broader socioeconomic context—documented in our previous work—provides important framing for interpreting these AVF outcomes. The ability to achieve 73.7% one-year patency in this challenging context demonstrates that quality vascular access care is attainable even in resource-limited, geographically isolated settings with substantial socioeconomic barriers. This finding may have important implications for other underserved regions facing similar challenges. Environmental factor: Climate season The relationship between climatic conditions and AVF patency in Amazonian/tropical environments remains unknow. We explored whether the season of AVF creation (wet vs. dry) influenced outcomes in French Guiana’s Amazonian climate. Our analysis did not reveal a significant direct association between season and patency at either 6 weeks (OR = 1.15 [0.57–2.32], p = 0.703) or one year (OR = 1.52 [0.83–2.79], p = 0.174) when season was considered as a main effect. However, exploratory analysis suggested a possible interaction between season and initial arterial flow, wherein the effect of low flow on patency appeared more pronounced during the wet season (interaction OR = 0.15 [0.02–1.04], p = 0.05). This finding should be interpreted with considerable caution for several reasons: First, the confidence interval is wide and marginally significant ( p = 0.05), making it compatible with no effect. The point estimate suggests a strong interaction, but the precision is limited. Second, this was an exploratory, post-hoc analysis that emerged from subgroup examination rather than an a priori hypothesis. Third, the mechanistic explanations we propose—including peripheral vasoconstriction in cooler rainy season temperatures reducing arterial flow, increased infection risk from humidity and dermatitis, and dehydration-related hemoconcentration during hot periods—remain speculative. We did not directly measure temperature, humidity, rainfall intensity, infection rates, or hydration status. These mechanisms are biologically plausible and supported by general physiological literature [ 45 – 50 ], but have not been specifically validated in the context of AVF maturation. Finally, seasonal variation in French Guiana may correlate with unmeasured confounders such as healthcare staffing patterns, patient care-seeking behavior, or other temporal factors not captured in our analysis. Despite these limitations, the potential vulnerability of low-flow AVFs during the wet season warrants further investigation. If validated in prospective studies with direct environmental measurements and adequate power for subgroup analysis, this finding could inform timing of elective AVF creation or intensified monitoring protocols for hemodynamically marginal fistulas during high-risk periods. Currently, however, this observation should be considered hypothesis-generating rather than practice-changing. Generalizability and external validity Studies from Singapore, Malaysia, and Brazil have documented AVF patency rates and predictors of maturation in populations with similar climatic conditions to French Guiana. Studies in this country have been reported primary patency rates at 12 months between 62.9 and 72% comparable to our findings of 73.7% [ 6 , 7 , 42 ]. Vein and artery diameter were also associated with successful maturation in another Brazilian study. However, to our knowledge, no previous studies have specifically examined seasonal effects on AVF outcomes in these settings. Our exploratory finding of possible seasonal vulnerability in low-flow AVFs during the wet season therefore represents a novel hypothesis that could be tested in other tropical dialysis centers with similar climatic patterns. Moreover, the core associations we observed (particularly the strong predictive value of vascular parameters (arterial flow and diameter) and the adverse effects of obesity and smoking) are consistent with international literature spanning diverse geographical and climatic settings. These appear to represent universal biological principles of AVF maturation and function. Limitations of the work and potential biases This study has several limitations that should be acknowledged. Selection bias: The 23% catheter prevalence in our dialysis population suggests that patients with anticipated poor vascular anatomy may have been preferentially assigned to tunneled catheters rather than AVF creation. This selection process, while clinically appropriate, may have resulted in a cohort with more favorable baseline vascular characteristics, potentially overestimating patency rates compared to an unselected population. The favorable vascular parameters observed in our cohort (mean flow 966 mL/min, mean radial diameter 2.88 mm) support this hypothesis. Survivor bias: Our one-year patency analysis inherently excludes patients who died, received kidney transplants, or transferred care before 12 months. We did not formally account for competing risks (death, transplantation) in our statistical models. Future prospective studies should employ competing risk survival analysis methods to provide more robust estimates of AVF durability in this population. Information bias: First, its retrospective design limits the ability to infer causality and exposes the results to potential information bias, although data quality was enhanced by the use of the national REIN registry. Second, certain clinical variables known to influence AVF maturation (such as detailed cardiovascular status, inflammatory markers, or precise hydration status at the time of surgery) were not systematically available and could not be included in the analyses. Third, Doppler measurements were performed in routine clinical practice rather than within a standardized research protocol, which may have introduced inter-operator variability. However, the strong and consistent associations observed despite this potential dilution effect suggest robust underlying relationships. Fourth, although climatic season was included in the analysis, more granular environmental indicators (temperature, humidity, rainfall intensity) were not available; these aggregated measures may therefore not fully capture the complexity of environmental influences on vascular access outcomes. Socioeconomic and Geographic Factors: While we have extensively characterized the socioeconomic context of French Guiana in previous publications [ 13 , 14 ] this retrospective analysis did not include granular individual-level socioeconomic data (income, education, precise travel distance). Future prospective studies should systematically collect these variables to better understand how social determinants modify the relationship between vascular parameters and AVF outcomes. Conclusion In French Guiana, AVF patency at one year depends mainly on initial vascular parameters, but is also influenced by smoking, obesity, the number of previous fistulas, and the season of creation. These results highlight the need for rigorous preoperative assessment and enhanced monitoring, particularly for low-flow AVFs and during the wet season. Prospective studies are needed to clarify local mechanisms, particularly infectious and climatic ones. Acknowledgements The authors gratefully acknowledge: Dr. Cécile Couchoud (Agence de la biomédecine, REIN registry) for critical review of the manuscript. The Agence de la biomédecine for providing access to REIN registry data and for technical support throughout the study. The clinical staff at Cayenne Hospital Center, particularly the nephrology, vascular surgery, and dialysis teams, for their meticulous clinical documentation that made this study possible. All patients whose anonymized data contributed to this research.Writing assistance and AI tools: No professional writing assistance or artificial intelligence tools were used in the preparation of this manuscript. All content was generated by the authors. Abbreviations AVF Arteriovenous fistula BMI Body mass index HIV Human immunodeficiency virus HCV Hepatitis C virus HBV Hepatitis B virus ISN International Society of Nephrology KDOQI Kidney Disease Outcomes Quality Initiative OR Odd ratio PASS Permanence d’Accès aux Soins de Santé SD Standard deviation SR Sex ratio VIF Variance inflation factor Author contributions DRR: Conceptualization, Methodology, Formal analysis, Writing (Original Draft, writing), Review and editing, Project administration. DRR takes responsibility for the integrity of the data analysis. MN: Methodology, Formal analysis (verification), Writing (Review, Editing), Supervision. MN validated the statistical methods and results. TFB: Investigation, Data curation, Validation, Writing (Review). TFB contributed to clinical data collection and verification. MS: Investigation, Data curation, Validation, Writing (Review). MS contributed to clinical data collection and verification. TD: Investigation, Data curation, Validation, Writing (Review). TD contributed to clinical data collection and verification. MB: Investigation, Data curation, Validation, Writing (Review). MB contributed to clinical data collection and verification. MPJ: Investigation, Data curation, Validation, Writing (Review). MPJ contributed to clinical data collection and verification. KMS: Investigation, Data curation, Writing (Review), KMS performed patient screening and data entry. All authors contributed to the interpretation of results, critically revised the manuscript for important intellectual content, approved the final version, and agree to be accountable for all aspects of the work. Funding This study was supported by a research grant from the French Biomedicine Agency awarded through the 2022 Research Call for Proposals from the Epidemiology and Information Network in Nephrology (REIN), number: 22REIN08. The funding was specifically allocated to support data entry and management by a clinical research assistant. The funding body had no role in study design, data collection, data analysis or interpretation, writing of the manuscript, decision to submit the manuscript for publication. No author received direct personal funding, or honoraria from this grant. No other sources of funding supported this work. The authors declare no additional financial support from any other organization or entity. Data availability The datasets generated and analyzed during the current study are derived from the French REIN registry. Due to the French legal and regulatory restrictions governing health data (including requirements of the CNIL authorization and REIN registry governance rules), the raw patient-level data are not publicly available. Aggregated data supporting the findings of this study may be available from the corresponding author upon reasonable request and with the permission from the Agence de la biomédecine (REIN Registry governance body). Requests should be include a detail research proposal describing the intended use, evidence of appropriate ethics approval from the requesting institution, and a data sharing agreement compliant with GDPR and French data protection laws. The REIN registry data access procedures are governed by the Agence de la biomédecine and detailed information can be found at ( https://www.agence-biomedecine.fr ). Declarations Ethics approval and consent to participate Ethics approval: This retrospective observational study was conducted in accordance with the ethical principles of the Declaration of Helsinki and French legislation on the protection of personal data (General Data Protection Regulation – GDPR, and French Data Protection Act). The study utilized data from the Epidemiology and Information Network in Nephrology (REIN) registry, which operates under authorization from the French National Commission on Informatics and Liberty (CNIL), authorization number 903188. All patient data were anonymized prior to analysis. Under French law (Article L.1121-1 of the Public Health Code), retrospective studies using previously collected, anonymized data from authorized registries do not require additional ethics committee approval. Nevertheless, the study protocol was reviewed in accordance with local institutional policies governing retrospective. Consent to participate: Individual informed consent was not required for this retrospective registry-based study under French regulations governing the use of anonymized health data (Article 54 of the French Data Protection Act modified by Law 2016-41 of 26 January 2016). All patients included in the REIN registry are informed of data collection and retention at the time of registry enrollment and have the right to object to the use of their data. No patients in our cohort exerciced this right of objection. This approach was confirmed as appropriate by the REIN registry governance body (Agence de la biomédecine). Consent for publication Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos). All data are presented in aggregate form only, derived from fully anonymized retrospective records. Under these circumstances, individual consent for publication is not required according to BMC editorial policies and French data protection regulations. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. 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Requests should be include a detail research proposal describing the intended use, evidence of appropriate ethics approval from the requesting institution, and a data sharing agreement compliant with GDPR and French data protection laws. The REIN registry data access procedures are governed by the Agence de la biomédecine and detailed information can be found at ( https://www.agence-biomedecine.fr ). 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