AV fistula for dialysis access linked to greater cumulative catheter dependency
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For older patients who initiated hemodialysis without permanent access, those with arteriovenous fistula placement within the following year were catheter-dependent for more time cumulatively than those with AV graft.
“An optimally functioning AVF is desirable as it is associated with better access survival than an AVG,” Beini Lyu, MD, of the department of population health sciences at the University of Wisconsin School of Medicine and Public Health, and colleagues wrote. “This benefit, however, is dependent on successful maturation of the access. Successful maturation of an AVF prior to use takes an average of 3 [to] 4 months, but can be considerably longer if interventions are required to assist maturation. Catheter use remains necessary during this time.”
The researchers contended that, despite observed associations between AVF placement and improved access survival in the long-term (and, in turn, potential reductions in long-term catheter dependency), older patients may not benefit because up to 50% of AVFs do not mature.
“As older patients initiating hemodialysis have a lower probability of AVF maturation and limited life expectancy, it is not clear whether such patients reap these potential long-term benefits of AVF,” they wrote.
Using the U.S. Renal Data System, researchers identified patients 67 years or older who had a first AVF (n = 14,532) or AVG (n = 3,391) placed within 1 year after hemodialysis initiation.
While patients with AVF placement had lower catheter dependence at 12 and 36 months compared with those who had AVG (14.2% vs. 15.8% and 8.2% vs. 15%, respectively), the researchers observed AVF placement was associated with greater cumulative catheter dependency.
More specifically, creation of an AVF was associated with greater catheter dependence at 1 month (95.6% vs. 92.5%) and 3 months (82.8% vs. 41.2%); AVF was also linked to greater cumulative catheter-dependent days (80.1 vs. 54.6 days per person-year) and a lower proportion of catheter-free survival time (78.1% vs. 85.1%) at 3 years.
“As expected, AVF was associated with longer catheter dependence in the first year after AVF/AVG placement in our analyses,” Lyu and colleagues wrote. “However, we found AVF creation remains associated with greater catheter-dependent days and an overall lower proportion of catheter-free survival in elderly patients over 3 years of follow-up. Our results suggest that AVFs’ theoretical overall long-term benefit of lower catheter dependence is not realized in many elderly patients.”
Based on these findings, the researchers emphasized the importance of considering specific patient characteristics in vascular access decision-making.
“Overall, individualized ‘patient-first approach’ should be applied when determining the optimal vascular access type for elderly patients,” they concluded.
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