Patients started on hemodialysis with tunneled dialysis catheter have similar survival after arteriovenous fistula and arteriovenous graft creation

Abstract

OBJECTIVES Current guidelines suggest that arteriovenous fistula (AVF) is associated with survival advantage over arteriovenous grafts (AVG). However, AVF often require months to become functional, increasing tunneled dialysis catheter (TDC) use, which can erode the benefit of AVF. We sought to compare survival in ESRD patients after creation of AVF or AVG in patients starting hemodialysis (HD) with TDC and identify patient populations that may benefit from preferential use of AVG over AVF. METHODS Using U.S. Renal Data System (USRDS) databases, we identified incident HD patients in 2005 through 2008 and followed them through 2008. Initial access type and clinical variables including albumin levels were assessed using USRDS data collection forms. Attempts at AVF and AVG creation in patients who started HD through TDC were identified by CPT codes. We accounted for the effect of changes in access type by truncating follow-up when additional AVF or AVG were performed. Survival curves were then constructed, and log-rank tests used for pairwise survival comparisons, stratified by age. Multivariate analysis was performed with Cox proportional hazards regressions; variables were chosen using stepwise elimination. An interaction of access type and albumin level was detected, and Cox models using differing thresholds for albumin level were constructed. The primary outcome was survival. RESULTS Among the 138,245 patients who started with TDC and had complete records amenable for analysis, 22.8% underwent AVF creation (Mean age±SD: 68.9±12.5 years, 27.8% mortality at 1 year) and 7.6% underwent AVG placement (70.2±12.0 years, 28.2% mortality) within 3 months of HD initiation; 69.6% remained with TDC (63.2±15.4 years, 33.8% mortality). In adjusted Cox proportional hazards regression, AVF creation is equivalent to AVG placement in terms of survival (HR 0.98, 95% CI 0.93–1.02; P=.349). AVG placement is superior to continued TDC use (HR 1.54, 95% CI 1.48–1.61; P<.001). In patients over age 80 with albumin levels greater than 4.0 g/dL, AVF creation is associated with higher mortality hazard compared to AVG creation (HR1.22, 95% CI 1.04–1.43, P=.013). CONCLUSIONS For patients that start HD through TDC, placement of AVF and AVG are associated with similar mortality hazard. Further study is necessary in order to determine the ideal access for patients in whom the survival advantage of AVF over AVG is uncertain.

Fistula First Initiative: Historical Impact on Vascular Access Practice Patterns and Influence on Future Vascular Access Care

“…However, they clearly found that the overall survival was significantly worse in the catheter groups versus AVF or AVG group [42]. Yuo et al have shown that patients initiating hemodialysis with a CVC have similar survival after AVF and AVG creation[43]. In patients older than 80 years with albumin levels >4.0 g/dL, AVF creation is associated with higher mortality compared with AVG creation [43].…”

“…Yuo et al have shown that patients initiating hemodialysis with a CVC have similar survival after AVF and AVG creation[43]. In patients older than 80 years with albumin levels >4.0 g/dL, AVF creation is associated with higher mortality compared with AVG creation [43]. This may likely be due to earlier removal of CVC in patients with AVG compared to AVF [44].…”

“…AVGs in pre-dialysis patients placed closer to time of hemodialysis initiation has been shown to be an effective CVC sparing strategy [65]. Furthermore, patients initiating dialysis with a CVC and later having AVF or AVG creation have been shown to have similar mortality rates [43]. …”

Vascular access for hemodialysis: A perpetual challenge

“…Clinical practice guidelines are largely conceived as tools that standardize health professionals' decisions rather than foster customized care or patient involvement in decision making. An emerging body of literature shows that the association between patient survival and vascular access used at dialysis initiation is a surrogate of better health status in those having undergone creation of a fistula or using a fistula . In several studies, the survival advantage associated with removal of the catheter was similar whether patients converted to fistula or graft .…”

“…An emerging body of literature shows that the association between patient survival and vascular access used at dialysis initiation is a surrogate of better health status in those having undergone creation of a fistula or using a fistula. [54][55][56] In several studies, the survival advantage associated with removal of the catheter was similar whether patients converted to fistula or graft. 48,55,57 The relative benefit of fistulas may vary depending on the patient population, modulated by age and comorbidities, such that the benefits of arteriovenous fistula over those of arteriovenous graft dissipate in older patients.…”