Transplant waitlisting attenuates the association between hemodialysis access type and mortality

Area of Science:

• Nephrology
• Vascular Surgery
• Public Health

Background:

• Hemodialysis (HD) is a life-sustaining treatment for end-stage renal disease (ESRD).
• The type of vascular access used for HD (arteriovenous fistula (AVF), arteriovenous graft (AVG), or hemodialysis catheter (HC)) significantly impacts patient outcomes.
• Prior research indicates that HC use is associated with higher mortality compared to AVF or AVG.

Purpose of the Study:

• To investigate whether kidney transplant waitlisting modifies the association between HD access type and mortality.
• To evaluate the differential impact of HD access on mortality among ESRD patients who are waitlisted versus not waitlisted for transplantation.

Main Methods:

• Retrospective cohort study using the US Renal Data System (USRDS).
• Inclusion of patients initiating HD between 2010 and 2015.
• Analysis using Cox regression with an interaction term for HD access type and transplant waitlist status.

Main Results:

• Among patients not on the transplant waitlist, AVF and AVG were associated with significantly lower mortality compared to HC.
• Transplant waitlisting attenuated the mortality benefit of both AVF and AVG compared to HC.
• Among waitlisted patients, AVF showed a modest mortality reduction versus HC, while AVG showed no significant difference.

Conclusions:

• While AVF and AVG are preferable to HC for HD access, their survival benefit is diminished in transplant waitlisted patients.
• Strategies to improve health status and healthcare access for non-waitlisted ESRD patients may reduce HD-associated mortality.
• Optimizing vascular access placement and timely transplantation remain critical for improving ESRD patient survival.