Comparison of different interventions for promoting the maturation of autogenous arteriovenous fistula: A systematic review and Bayesian network meta-analysis

Objective: Autogenous arteriovenous fistula (AVF) is the preferred access for patients undergoing hemodialysis. This study sought to identify the optimal intervention for promoting the maturation of AVFs through a network meta-analysis (NMA). Methods: Cochrane Library, Embase, PubMed, and Web of Science databases were searched by computer for publications up to May 12, 2025, utilizing primary terms such as “arteriovenous fistula” and “maturation.” Risk of bias was assessed utilizing the tool from the Cochrane Handbook for Systematic Reviews. Funnel plots and Egger’s test were used to assess publication bias. Primary outcomes were the ultrasonographic and clinical maturation of AVFs. The secondary outcome was the vein diameter. An NMA was conducted employing a Bayesian random-effects or fixed-effects model. Mean differences (MD) and relative risks (RR) with 95% credible intervals (CrI) were calculated. Surface under the cumulative ranking curve (SUCRA) values were utilized to rank different interventions. Analyses were performed using R 4.3.2. Results: Finally, 11 RCTs involving 1202 patients were included. The studies encompassed a total of 5 interventions, namely isometric exercise (ISOM), isotonic exercise (ISOT), ISOM+ISOT, far infrared (FIR) therapy, and balloon-assisted maturation (BAM). The NMA revealed that compared with conventional care, ISOM ranked first in improving clinical maturation (RR = 1.4, 95% CrI: 1.2, 1.7, SUCRA = 98.07%) and ultrasonographic maturation (RR = 1.5, 95% CrI: 1.2, 1.8, SUCRA = 99.88%). ISOM+ISOT ranked first in increasing the diameter of the outflow vein (MD = 0.84, 95% CrI: 0.68, 1.0, SUCRA = 87.24%). Conclusion: This study suggests that, among the evaluated interventions, ISOM has the highest probability of improving clinical maturation of AVFs based on moderate-certainty evidence, and evidence supporting its effect on ultrasonographic maturation is tentative given the limited sample size ( n = 340). ISOM + ISOT demonstrated the greatest likelihood of effectively increasing vein diameter. These findings are probabilistic and require individualized application.