Vascular access placement and mortality in elderly incident hemodialysis patients

A meta-analysis of the impact of initial hemodialysis access type on mortality in elderly incident hemodialysis population

BACKGROUND

Selecting the appropriate vascular access type for elderly patients before initiating hemodialysis presents a challenge, given their limited life expectancy and multiple comorbidities. This systematic review aims to evaluate whether initial arteriovenous access (AVa), including arteriovenous fistulas (AVF) and/or arteriovenous grafts (AVG), offers a benefit in reducing the risk of all-cause mortality compared to central venous catheters (CVC) for patients aged ≥ 65 years.

METHODS

We conducted searches in PubMed (from 1946 to March 20, 2023), Embase (from 1947 to 20 March 20, 2023), and the Cochrane Library to identify studies comparing the use of CVC with AVa as the initial vascular access in hemodialysis patients aged ≥ 65 years. The primary outcome of interest was all-cause mortality. We pooled the hazard ratio (HR) and 95% confidence intervals (CIs) of the included studies using a random-effect model. The Newcastle-Ottawa Scale was employed to assess the risk of bias for each included study.

RESULTS

Ten studies involving over 300,000 patients were included, all of which were retrospective cohort studies. Compared to AVa, the use of CVC as the initial dialysis access is associated with a higher incidence of all-cause mortality in patients aged ≥ 65 years (HR = 1.53, 95%CI = 1.41-1.67, I2 = 74.9).

CONCLUSION

In this analysis, we observed an increased risk of death in elderly patients initiating dialysis with CVC compared to those using AVa. However, the retrospective cohort studies included in this analysis are susceptible to selection bias, indicating that further randomized controlled trials are necessary to confirm these findings.

FUNDING

This systematic review and meta-analysis were not funded.

REGISTRATION

The protocol of this systematic review has been registered in the PROSPERO registry (CRD42023435577; https://www.crd.york.ac.uk/prospero ).

Retrospective evaluation of three types of expanded polytetrafluoroethylene grafts for upper limb vascular access

Currently, three expanded polytetrafluoroethylene (ePTFE) prosthetic graft types are most commonly used for patients with end-stage kidney disease (ESKD) who require long-term vascular access for hemodialysis. However, studies comparing the three ePTFE grafts are limited. This study compared the clinical efficacy and postoperative complications of three ePTFE prosthetic graft types used for upper limb arteriovenous graft (AVG) surgery among patients with ESKD. Patients with ESKD requiring upper limb AVG surgery admitted to our center between January 2016 and September 2019 were enrolled. Overall, 282 patients who completed the 2-year follow-up were included and classified into the following three groups according to the ePTFE graft type: the GPVG group with the PROPATEN® graft, the GAVG group with the straight-type GORE® ACUSEAL, and the BVVG group with the VENAFLO® II. The patency rate and incidence of access-related complications were analyzed and compared between groups. The patients were followed up postoperatively, and data were collected at 6, 12, 18, and 24 months postoperatively. Respective to these follow-up time points, in the GPVG group, the primary patency rates were 74.29%, 65.71%, 51.43%, and 42.86%; the assisted primary patency rates were 85.71%, 74.29%, 60.00%, and 48.57%; and the secondary patency rates were 85.71%, 80.00%, 71.43%, and 60.00%. In the GAVG group, the primary patency rates were 73.03%, 53.93%, 59.42%, and 38.20%; the assisted primary patency rates were 83.15%, 68.54%, 59.55%, and 53.93%; and the secondary patency rates were 85.39%, 77.53%, 68.54%, and 62.92%, respectively. In the BVVG group, the primary patency rates were 67.24%, 53.45%, 41.38%, and 29.31%; the assisted primary patency rates were 84.48%, 67.24%, 55.17%, and 44.83%; and the secondary patency rates were 86.21%, 81.03%, 68.97%, and 60.34%, respectively. The differences in patency rates across the three grafts were not statistically significant. Overall, 18, 4, and 12 patients in the GPVG, GAVG, and BVVG groups, respectively, experienced seroma. Among the three grafts, GORE® ACUSEAL had the shortest anastomosis hemostatic time. The first cannulation times for the three grafts were GPVG at 16 (±8.2), GAVG at 4 (±4.9), and BVVG at 18 (±12.7) days. No significant difference was found in the postoperative swelling rate between the GPVG group and the other two groups. Furthermore, no statistically significant differences were found across the three graft types regarding postoperative vascular access stenosis and thrombosis, ischemic steal syndrome, pseudoaneurysm, or infection. In conclusion, no statistically significant differences in the postoperative primary, assisted primary, or secondary graft patency rates were observed among the three groups. A shorter anastomosis hemostatic time, first cannulation time, and seroma occurrence were observed with the ACUSEAL® graft than with its counterparts. The incidence of upper extremity swelling postoperatively was greater with the PROPATEN® graft than with the other grafts. No statistically significant differences were observed among the three grafts regarding the remaining complications.

The effect of early conversion from central venous catheter to arteriovenous fistula on hospitalization and mortality in incident haemodialysis patients

BACKGROUND

Controversy remains as to whether initiating haemodialysis (HD) with a central venous catheter (CVC) and vascular access conversion are associated with the risk of morbidity and mortality in incident HD patients.

METHODS

At our dialysis centre, the vascular access strategy is to create an arteriovenous fistula (AVF) early and use the AVF to initiate HD. In emergency situations, HD is initiated with a CVC and subsequent conversion from a CVC to an AVF as soon as possible. The effects of early AVF conversion on hospitalization and mortality were analysed.

RESULTS

At HD initiation, 35.42% used AVF, 15.63% used CVC with immature AVF and 48.96% used CVC, and all patients were able to convert from CVC to AVF within approximately 3 months. Compared to starting HD using an AVF, using a CVC was associated with access-related hospitalizations at 2 years, regardless of whether an AVF was created before (incidence rate ratio (IRR) = 3.02, 95% CI 0.89-10.24, p = 0.03) or after (IRR = 4.10, 95% CI 1.55-10.85, p < 0.01) HD initiation. The Kaplan-Meier method showed that the 2-year survival probability was not statistically significant between the three groups (log-rank χ2 = 0.165, p = 0.921). Multivariate Cox proportional hazards regression showed that starting HD with a CVC was not associated with mortality at 2 years (p > 0.05).

CONCLUSION

In this cohort, initiating HD with a CVC was associated with more access-related hospitalizations. Under the impact of an early AVF conversion strategy, despite initiating HD with a CVC, subsequent conversion from a CVC to an AVF within approximately 3 months had no impact on all-cause mortality in incident HD patients.

Bacteremia and Mortality among Patients with Nontunneled and Tunneled Catheters for Hemodialysis

Introduction

Central venous catheters for hemodialysis (HD) can be nontunneled catheters (NTC) or tunneled catheters (TC). Bacteremia and dysfunction are complications that can impact morbidity and mortality. We decided to compare the rates of bacteremia and dysfunction between NTC and TC and patient survival 90 days after catheter insertion.

Methods

Retrospective cohort to evaluate catheters inserted between January 2011 and December 2020 in a tertiary hospital. Catheters in patients with end-stage chronic kidney disease were included. Patients with acute kidney injury, catheters that lasted less than three HD sessions, and patients who died within one week after insertion were excluded. Bacteremia and dysfunction rates, bacteremia-free survival, and dysfunction-free survival were investigated. Multivariable analysis was performed using a Cox proportional hazards regression model for patient survival at 90 days.

Results

670 catheters were analyzed in 287 patients, 422 NTC (63%), and 248 TC (37%). The rates of confirmed bacteremia per 1,000 catheter-days were 1.19 for NTC and 0.20 for TC (p < 0.0001). The confirmed or possible bacteremia rates were 2.27 and 0.37 per 1,000 catheter-days for NTC and TC, respectively (p < 0.0001). The dysfunction rates were 3.96 and 0.86 for NTC and TC, respectively (p < 0.0001). Patient survival at 90 days was higher in the TC group than the NTC group (96.8% vs. 89.1%; p < 0.0001).

Conclusion

We found lower rates of bacteremia and dysfunction for TC and demonstrated that using NTC affects patient mortality.

Hemodialysis vascular access in elderly patients: A comprehensive review

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.

Age-based comparison of vascular access outcomes in maintenance hemodialysis population

INTRODUCTION

The hemodialysis population is aging, worldwide. In Israel, more than half of the dialysis population is older than 68 years. The policy for vascular access among this population is still a matter of debate, with several studies demonstrating conflicting results. This study compared vascular access outcomes across age groups (<65, 65-75, >75 years) in a single hemodialysis center in Israel.

METHODS

This was a retrospective, single center analysis of all vascular accesses created in adult hemodialysis patients in our institution, from January 1, 2006, through December 31, 2012. Patient characteristics, primary and secondary access failure, and complications were collected from electronic medical records. Follow-up was until death or up to 5 years.

RESULTS

A total of 612 vascular accesses created among maintenance hemodialysis patients were included, of which 196 were in patients >75 years, 184 in patients 65-75 years, and 232 in patients <65 years. Mean age of the >75 years group was 80.5 ± 4.3 years and 60.7% were men. Vascular access site was the most important predicator for primary access failure (odds ratio for primary failure of radiocephalic arteriovenous fistula was 3.5 (95% CI 2.1-6), whereas age did not affect the primary failure rate (odds ratio 1.5, p = 0.648). Radiocephalic fistulas were more prone to secondary failure than other vascular access sites were. Complications were slightly more common in the oldest group. Eight percent of the patients >75 years died before access was used.

CONCLUSIONS

In our cohort, age did not affect vascular outcomes, whereas VA site seemed to be the most important parameter in primary and secondary VA failures. Our results support considering VA on an individual basis and supply valuable information regarding complication and failure rates of VA among patients >75 years.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

Health care disparities involved in establishing functional arteriovenous fistula hemodialysis access

OBJECTIVE

Race-related disparities in outcomes associated with cardiovascular disease are well-documented. Arteriovenous fistula (AVF) maturation can be a challenge in establishing functional access in the population of patients with end-stage renal disease requiring hemodialysis. We sought to investigate the incidence of adjunctive procedures required to establish fistula maturation and evaluate the association with demographic factors including patient race.

METHODS

This study was a single-institution retrospective review of patients undergoing first-time AVF creation for hemodialysis from January 1, 2007, to December 31, 2021. Subsequent arteriovenous access interventions, such as percutaneous angioplasty, fistula superficialization, branch ligation and embolization, surgical revision, and thrombectomy, were recorded. The total number of interventions performed after index operation was recorded. Demographic data including age, sex, race, and ethnicity was recorded. The need for and number of subsequent interventions was evaluated using multivariable analysis.

RESULTS

A total of 669 patients were included in this study. Patients were 60.8% male and 39.2% female. Race was reported as White in 329 (49.2%), Black in 211 (31.5%), Asian in 27 (4.0%), and other/unknown in 102 (15.3%). Of the patients, 355 (53.1%) underwent no additional procedures after initial AVF creation, 188 (28.1%) underwent one additional procedure, 73 (10.9%) had two additional procedures, and 53 (7.9%) had three or more additional procedures. As compared with the White reference group, Black patients were at higher risk of having maintenance interventions (relative risk [RR], 1.900; P ≤ .0001) and additional AVF creation interventions (RR, 1.332; P = .05), and total interventions (RR, 1.551; P ≤ .0001).

CONCLUSIONS

Black patients were at significantly higher risk of undergoing additional surgical procedures, including both maintenance and new fistula creations, as compared with their counterparts of other racial groups. Further exploration of the root cause of these disparities is necessary to facilitate the achievement of equivalent high-quality outcomes across racial groups.

Vascular access type and mortality in elderly incident hemodialysis patients

INTRODUCTION

The ideal vascular access type for elderly hemodialysis (HD) patients remains debatable. The aim of this study was to analyze the association between patterns of vascular access use within the first year of HD and mortality in elderly patients.

METHODS

Single-center retrospective study of 99 incident HD patients aged≥80 years from January 2010 to May 2021. Patients were categorized according to their patterns of vascular access use within the first year of HD: central venous catheter (CVC) only, CVC to arteriovenous fistula (AVF), AVF to CVC, and AVF only. Baseline clinical data were compared among groups. Survival outcomes were analyzed using Kaplan-Meier survival curves and Cox's proportional hazards model.

RESULTS

When compared with CVC to AVF, mortality risk was significantly higher among CVC only patients and similar to AVF only group [HR 0.93 (95% CI 0.32-2.51)]. Ischemic heart disease [HR 1.74 (95% CI 1.02-2.96)], lower levels of albumin [HR 2.16 (95% CI 1.28-3.64)] and hemoglobin [HR 4.10(95% CI 1.69-9.92)], and higher levels of c-reactive protein [HR 1.87(95% CI 1.11-3.14)] were also associated with increased mortality risk in our cohort, p<0.05.

CONCLUSION

Our findings suggested that placement of an AVF during the early stages of dialysis was associated with lower mortality compared to persistent CVC use among elderly patients. AVF placement appears to have a positive impact on survival outcomes, even in those who started dialysis with a CVC.

Identification and Validation of Hub Genes in the Stenosis of Arteriovenous Fistula

Arteriovenous fistula (AVF) is the most widely used hemodialysis vascular access in China. However, stenosis of the AVF limits its use. The mechanism of AVF stenosis is currently unknown. Therefore, the purpose of our study was to explore the mechanisms of AVF stenosis. In this study, we identified the differentially expressed genes (DEGs) based on the Gene Expression Omnibus (GEO) dataset (GSE39488) between venous segments of AVF and normal veins. A protein-protein interaction (PPI) network was constructed to identify hub genes of AVF stenosis. Finally, six hub genes (FOS, NR4A2, EGR2, CXCR4, ATF3, and SERPINE1) were found. Combined with the results of the PPI network analysis and literature search, FOS and NR4A2 were selected as the target genes for further investigation. We validated the bioinformatic results via reverse transcription PCR (RT-PCR) and Western blot analyses on human and rat samples. The expression levels of the mRNA and protein of FOS and NR4A2 were upregulated in both human and rat samples. In summary, we found that FOS may play an important role in AVF stenosis, which could be a potential therapeutic target of AVF stenosis.

Unplanned hemodialysis initiation and low geriatric nutritional risk index scores are associated with end-stage renal disease outcomes

Patients with end-stage renal disease (ESRD) have a low nutritional status and a high mortality risk. The geriatric nutritional risk index (GNRI) is a predictive marker of malnutrition. However, the association between unplanned hemodialysis (HD) and GNRI with mortality remains unclear. In total, 162 patients underwent HD at our hospital. They were divided into two groups: those with unplanned initiation with a central venous catheter (CVC; n = 62) and those with planned initiation with prepared vascular access (n = 100). There were no significant differences in sex, age, malignant tumor, hypertension, and vascular disease, while there were significant differences in the times from the first visit to HD initiation (zero vs. six times, p < 0.001) and days between the first visit and HD initiation (5 vs. 175 days, p < 0.001). The CVC insertion group had significantly lower GNRI scores at initiation (85.7 vs. 99.0, p < 0.001). The adjusted hazard ratios were 4.002 and 3.018 for the GNRI scores and frequency, respectively. The 3-year survival rate was significantly lower in the CVC + low GNRI group (p < 0.0001). The GNRI after 1 month was significantly inferior in the CVC insertion group. Inadequate general management due to late referral to the nephrology department is a risk factor for patients with ESRD.

Arteriovenous Vascular Access-Related Procedural Burden Among Incident Hemodialysis Patients in the United States

RATIONALE & OBJECTIVE

As the proportion of arteriovenous fistulas (AVFs) compared with arteriovenous grafts (AVGs) in the United States has increased, there has been a concurrent increase in interventions. We explored AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

Patients initiating hemodialysis from July 1, 2012, to December 31, 2014, and having a first-time AVF or AVG placement between dialysis initiation and 1 year (N = 73,027), identified using the US Renal Data System (USRDS).

PREDICTORS

Patient characteristics.

OUTCOME

Successful AVF/AVG use and intervention procedure burden.

ANALYTICAL APPROACH

For each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modeling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase.

RESULTS

During the maturation phase, 13,989 of 57,275 patients (24.4%) in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person. In the AVG group 2,904 of 15,572 patients (18.4%) required intervention during maturation, with therapeutic interventional requirements of 0.28 per person. During the maintenance phase, in the AVF group 12,732 of 32,115 patients (39.6%) required intervention, with a therapeutic intervention rate of 0.93 per person-year. During maintenance phase, in the AVG group 5,928 of 10,271 patients (57.7%) required intervention, with a therapeutic intervention rate of 1.87 per person-year. For both phases, the intervention rates for AVF tended to be higher on the East Coast while those for AVG were more uniform geographically.

LIMITATIONS

This study relies on administrative data, with monthly recording of access use.

CONCLUSIONS

During maturation, interventions for both AVFs and AVGs were relatively common. Once successfully matured, AVFs had lower maintenance interventional requirements. During the maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.

Outcomes of arteriovenous fistula in elderly patients on maintenance haemodialysis

BACKGROUND

The optimal vascular access strategy in elderly patients receiving haemodialysis (HD) remains controversial. We aim to report the outcomes of arteriovenous fistula (AVF) in elderly patients initiated on maintenance HD in our centre.

METHODS

Medical records of 688 incident patients initiated on HD from 2010 to 2012 in a tertiary centre were retrospectively reviewed. Patients' characteristics and AVF outcomes were compared among those < 65 years (non-elderly), ≥ 65-75 years (early elderly) and ≥ 75 years (late elderly).

RESULTS

There were 418 non-elderly, 184 early elderly and 86 late elderly patients. There is a higher proportion of brachiocephalic and brachiobasilic fistula created in the late elderly (24.9% vs. 37.0% vs. 41.8%, p = 0.001). The outcomes of accesses created were comparable in the 3 age groups with similar proportions of functional AVFs (80.4% vs. 79.3% vs. 75.6%, p = 0.832) and comparable 1-, 3- and 5-year primary and secondary patency rates (p = 0.351 and 0.282, respectively). However, a longer maturation time (2.78 vs. 2.86 vs. 3.72 months, p = 0.010) and a higher mean number of interventions to assist maturation of the first AVF were required in late elderly patients (0.19 vs. 0.22 vs. 0.35, p = 0.014). Following AVF creation, median patient survival in the non-elderly, early and late elderly was 65.2 vs. 55.1 vs. 49.8 months respectively.

CONCLUSION

AVFs created in elderly patients have comparable outcomes compared to non-elderly patients although more interventions are required to assist maturation with a longer maturation time necessitating early access creation to allow for time needed due to maturation delay.

The survival analysis of tunnel-cuffed central venous catheter versus arteriovenous hemodialysis access among elderly patients: A retrospective single center study

BACKGROUND

There is currently a controversy for the optimal vascular access option in the elderly, regarding their multiple comorbidities and life expectancies. Our study aimed to compare the survival of tunneled cuff venous catheter (CVC) and arteriovenous access (AV access) in elderly patients.

METHODS

A retrospective cohort study was performed by electronic medical record review. All hemodialysis patients aged 65 years and over who firstly initiated dialysis from January 1, 2012 to December 31, 2016 at Siriraj hospital, Thailand, were included. The primary outcomes are to compare a 2-year period of survival between CVC and AV access in terms of abandonment, death, and combined outcome. Propensity score covariate and Charlson Comorbidity Score (CCI) were used for multivariable analysis adjustment.

RESULTS

A total of 359 patients were included; 216 (60.2%) patients had initiated hemodialysis via CVC while the rest used AV access. The patients' average ages were 76.7 ± 7.0 and 74.0 ± 5.8 years (p-value<0.001) in the CVC and AV access group, respectively. The 2-year mortality rates of CVC and AV access groups were 24.1% and 15.4%, respectively (p-value = 0.038). Multivariable analyses showed that the adjusted hazard ratio (aHR) of combined endpoints, i.e., vascular access abandonment and death, was statistically different only in the CCI-adjusted model (aHR = 0.68, 95% CI: 0.46-0.99). Mortality from infection cause was more common in the CVC group than the AV access group.

CONCLUSION

CVC access maybe considers an alternative option for frail elderly patients. However, the patient selection is a crucial issue, given higher infection-related mortality in patients using CVC.

Outcomes of arteriovenous access among cancer patients requiring chronic haemodialysis

Background

There are limited data focusing specifically on the types of arteriovenous (AV) access used and outcomes of AV access among cancer patients as a consequence of cancer. We aimed to describe outcomes of AV access among cancer patients requiring chronic haemodialysis, and also to compare outcomes between patients with and without cancer.

Methods

In this single-centre, retrospective, observational cohort study, 84 patients diagnosed with cancer before AV access placement were included; we analysed outcomes of AV access among these patients and compared these outcomes with our previous results. The study endpoints were AV access patency and early failure, defined as AV access abandonment within 12 months after AV access placement.

Results

Various cancer types, stages, and treatments were identified in our analysis. Autologous arteriovenous fistulas (AVFs) were used for 92.9% of this study population. Using our previous results for comparison, we found no significant difference in death-censored primary (P = 0.546) and secondary (P = 0.266) patency of AV access between patients with and without cancer; however, the rate of early AVF failure was statistically significantly higher among cancer patients (25.6% vs 13.9%; P = 0.008), and the most common cause of AVF failure was patient death. The rate of early failure was significantly higher among patients with advanced-stage cancer (59.1%) than among those with early-stage cancer (12.9%) (P <  0.001).

Conclusions

Although AV access patency rates were similar among patients with and without cancer in the death-censored analysis, cancer patients were more prone to early AVF failure, mainly due to cancer-associated deaths, and this consideration needs to be carefully balanced against individual patients’ life expectancies, according to cancer type and stage.

Vascular access type and mortality in haemodialysis: a retrospective cohort study

Background

Haemodialysis patients have a high mortality rate. Part of this can be attributed to vascular access complications. Large retrospective studies have shown a higher mortality in patients dialysed with a catheter, which is mostly ascribed to infectious complications. Since we observe very little infectious complications in our haemodialysis patients, the aim of our study was to assess if we could still detect a difference in survival according to vascular access type.

Methods

Patients that started chronic haemodialysis treatment between 1/1/2007 and 31/12/2016 at the ‘Universitair Ziekenhuis Brussel’ were retrospectively studied. The time to death was studied as a function of the two main vascular access types using survival analysis, considering the type of vascular access at the initiation of dialysis or as time varying, and accounting for the available baseline characteristics.

Results

Of 374 patients 309 (82.6%) initiated haemodialysis with a catheter, while 65 patients initiated with an arteriovenous access. Vascular access type during follow-up did not change in 74% of all patients. A Kaplan Meier plot did not suggest a survival dependent on the vascular access type at start. An extended cox proportional hazard analysis showed that vascular access type was not independently correlated with mortality. However, age, history of congestive heart failure and active cancer at initiation of dialysis were independently associated with mortality.

Conclusions

In this retrospective cohort study, haemodialysis vascular access type was not independently correlated with patient survival, even after taking into account change of vascular access over time.

Vascular access as a survival factor for the hemodialysis population: a retrospective study

BACKGROUND

The creation of vascular access is an essential condition for providing hemodialysis, which remains the only option for most patients suffering from end-stage renal disease. Selection of the type of vascular access affects patients' clinical outcomes, access maintenance frequency, risk of infection and major adverse cardiac events during dialysis. To improve the decision-making process, we performed a retrospective clinical data analysis of dialyzed patients and critically compared the survival rates between two types of vascular access applied during dialysis therapy during a 5 years follow-up period.

METHODS

Using nationally representative data from 18 dialysis centers across Slovakia, we explore and compare survival rates of 960 adult patients undergoing hemodialysis using either a central venous catheter (CVC) or an arteriovenous fistula (AVF). Length of dialysis, protein malnutrition and comorbidities were examined as possible covariates that might influence survival rates.

RESULTS

Chances of surviving for a one-year period were higher by 52% in AVF patients compared to CVC patients (HR 1.52; 95% CI 1.27-1.83; P<0.001) regardless of age, sex, nutritional status, time spent on dialysis and comorbidities. The presence of cardiac congestion (HR 1.26 [95% CI 1.06-1.50], P<0.01) and malnutrition (protein malnutrition: HR 0.98 [95% CI 0.96-1.00], P<0.05; lean tissue index: HR 0.79 [95% CI 0.67-0.93], P<0.01) decreases chances for survival.

CONCLUSIONS

A functional arteriovenous fistula is a significant predictor of survival in the population dependent on hemodialysis, independently of sociodemographic parameters and serious comorbidities. Therefore, if various types of vascular accesses are applicable for the patient, AVF should be prioritized over CVC.

Effects of patient age on patency of chronic hemodialysis vascular access

BACKGROUND

In this single-center, retrospective observational study, we assessed the long-term patency of vascular access (VA) after first VA placement to uncover independent risk factors associated with VA patency in Asian hemodialysis (HD) patients stratified by age. We also investigated factors associated with VA patency among older HD patients according to the type of VA in the overall study population.

METHODS

The study period was from January 2011 to December 2013. A total of 651 chronic HD patients with confirmed first upper-extremity VA placement were enrolled, and their records were analyzed retrospectively. A total of 445 patients (68.4%) made up the nonelderly group (< 65 years), and 206 patients (31.6%) were in the elderly group (≥ 65 years). Study outcomes were defined as primary or secondary VA patency.

RESULTS

Autologous arteriovenous fistula (AVF) was more common in the nonelderly group (P <  0.01). Kaplan-Meier curve survival analysis indicated that primary patency was longer in the nonelderly group (P <  0.01); secondary patency, however, was similar between groups (P = 0.37). The multivariate analysis of factors associated with primary VA patency revealed that increased age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P <  0.01) was associated with shorter primary patency, and AVF (HR, 0.38; 95% CI, 0.28-0.51; P <  0.01) was associated with longer primary patency. AVF (HR, 0.57; 95% CI, 0.37-0.87; P = 0.010) and diabetes mellitus (HR, 1.56; 95% CI, 1.07-2.29; P = 0.02) were independently associated with longer and shorter secondary patency periods, respectively; however, increased age was not a risk factor for decreased secondary patency.

CONCLUSIONS

Increased age was associated with shorter primary patency but not secondary patency, whereas AVF placement was associated with longer primary and secondary patency. Considering the similar rates of secondary patency between groups and the superior patency of AVF compared to arteriovenous graft, a fistula-first strategy should be applied to appropriate older patients.

Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation

In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) were included and analyzed retrospectively. The study outcome was defined as AVF patency and all-cause mortality (time to death). On Kaplan-Meier survival analysis, primary and secondary AVF patency rates did not differ significantly between the two groups (P = 0.812 and P = 0.586, respectively), although the overall survival rate was significantly higher in the pre-HD group compared with the on-HD group (P = 0.013). On multivariate analysis, well-known patient factors were associated with decreased primary (older age and diabetes mellitus [DM]) and secondary (DM and peripheral arterial occlusive disease) AVF patency, whereas use of a CVC as the initial predialysis access (hazard ratios, 1.84; 95% confidence intervals, 1.20-2.75; P = 0.005) was significantly associated with worse survival in addition to well-known patient factors (older age, diabetes mellitus, and peripheral arterial occlusive disease). Worse survival in the on-HD group was likely confounded by selection bias because of the retrospective nature of our study. Therefore, the observed lower mortality associated with AVF creation before HD initiation is not fully attributable to CVC use, but rather, affected by other patient-level prognostic factors. There were no CVC-related complications in the pre-HD group, whereas 10.2% of CVC-related complications were noted in the on-HD group. In conclusion, among incident HD patients, compared with patients who underwent creation of an AVF from a CVC, initial AVF creation showed similar primary and secondary AVF patency rates, but lower mortality risk. We also observed that an initial CVC use was an independent risk factor associated with worse survival. A fistula-first strategy might be the best option for incident HD patients who are good candidates for AVF creation.