Arteriovenous access types demonstrate similar risk profiles
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The type of arteriovenous access placement, graft or fistula, used first in older patients receiving hemodialysis did not impact their risk for death, sepsis or hospitalization.
However, an arteriovenous fistula (AVF) was associated with a lower incidence of mortality and hospitalization within 6 months after placement.
“It is not clear whether creation of an AVF or placement of an [arteriovenous graft] AVG results in better outcomes among older patients receiving chronic hemodialysis. Previous observational studies on this topic have often suffered from potential biases,” Beini Lyu, MD, a doctoral student in the department of population health sciences at the University of Wisconsin, and Brad C. Astor, PhD, MPH, a professor of the division of nephrology and department of population health sciences at the University of Wisconsin, told Healio Nephrology. “Ideally, this question would be answered by a randomized controlled trial (RCT), but such data are not yet available. We aimed to emulate an RCT using data from the [U.S. Renal Data System] USRDS to compare the effect of AVF vs. AVG placement on several critical outcomes among elderly patients on hemodialysis.”
Lyu and colleagues examined the evidence supporting an optimal first choice of vascular access for older patients on hemodialysis. In this retrospective cohort study, they used target trial emulation to compare the effect of AVF vs. AVG on risk of all-cause mortality, all-cause and cause-specific hospitalization and sepsis. Researchers extracted data from the U.S. Renal Data system from 2019 to 2016 on patients aged 67 years or older at hemodialysis initiation with an AVF or AVG placed for the first time within 6 months of hemodialysis.
Among the 19,867 patients included in the study, 80.1% received an AVF and 19.9% an AVG. Lyu and colleagues noticed patients who received an AVF were younger, more likely to be male and white patients, had longer nephrologist care prior to end-stage kidney disease, had a slightly higher BMI, and were less likely to have dietician care prior to ESKD than those who had an AVG. Patients who received an AVF were less likely to have chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease and transient ischemic attack or congestive heart failure and were more likely to be independent. They were also less likely to be on Medicaid and more likely to receive hemodialysis at a hospital-based or nonprofit facility, according to researchers.
Compared with AVG, AVF placement had no effect on all-cause hospitalization, cardiovascular disease, infection-related hospitalization or sepsis.
“Similar to mortality, we found that AVF placement was associated with a substantially lower risk of hospitalization and sepsis early after placement in IPTW analysis but not in instrumental variable analysis which is most likely explained by patient selection,” Lyu and colleagues wrote in their study.
“Our results suggest that AVF and AVG placement have similar risks of subsequent mortality, sepsis and hospitalization among elderly patients who started hemodialysis with a catheter,” Lyu and Astor said. “These results add to the growing literature suggesting an AVF is not always preferred over an AVG for elderly patients. Clinicians should consider relevant patient characteristics and make individualized therapy choices when deciding on an AV access.”
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