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Catheter Dependence After Arteriovenous Fistula or Graft Placement Among Elderly Patients on Hemodialysis

Beini Lyu¹, Micah R Chan², Alexander S Yevzlin³

¹Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI.

American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation

|February 14, 2021

Insights

Elderly patients initiating hemodialysis (HD) with an arteriovenous fistula (AVF) experienced greater initial catheter dependence than those with an arteriovenous graft (AVG). Long-term benefits of AVF in reducing catheter dependence were not realized in this population.

Area of Science:

Nephrology
Vascular Surgery
Geriatrics

Background:

Arteriovenous fistula (AVF) and arteriovenous graft (AVG) are common vascular access methods for hemodialysis (HD).
While AVF generally offers longer-term benefits, its initial catheter dependence and long-term efficacy in elderly patients initiating HD without prior permanent access are not well-established.

Purpose of the Study:

To assess and compare catheter dependence following AVF versus AVG placement in elderly patients initiating HD.
To determine if the long-term advantages of AVF in reducing catheter dependence extend to the elderly population.

Main Methods:

Retrospective cohort study utilizing the US Renal Data System.
Included patients aged 67 years or older who initiated HD with either an AVF or AVG within one year of starting dialysis.
Analyzed catheter dependence using generalized estimating equations, negative binomial regression, and Cox proportional hazards models.

Main Results:

AVF placement was associated with higher initial catheter dependence at 1 and 3 months compared to AVG.
Despite initial differences, AVF showed lower catheter dependence at 12 and 36 months.
However, AVF resulted in significantly more cumulative catheter-dependent days and less catheter-free survival time over 3 years in this elderly cohort.

Conclusions:

In elderly patients initiating HD without permanent access, AVF creation leads to greater cumulative catheter dependence compared to AVG.
The anticipated long-term benefits of AVF in reducing catheter dependence may not be fully realized in this specific demographic.
Patient-specific factors should guide vascular access decisions in elderly individuals undergoing HD.

Read full analysis

Abstract

Rationale & Objective:

Creation of an arteriovenous fistula (AVF), compared with an arteriovenous graft (AVG), is associated with longer initial catheter dependence after starting hemodialysis (HD) but longer access survival and lower long-term catheter dependence. The extent of these potential long-term benefits in elderly patients is unknown. We assessed catheter dependence after AVF or AVG placement among elderly patients who initiated HD without a permanent access in place.

Study Design:

Retrospective cohort study.

Setting & Participants:

Patients≥67 years of age identified in the US Renal Data System who had a first AVF (n=14,532) or AVG (n=3,391) placed within 1 year after HD initiation between May 2012 and May 2017.

Exposure:

AVF versus AVG placement in the first year of HD.

Outcome:

Catheter dependence after AVF or AVG placement assessed using CROWNWeb data.

Analytical Approach:

Generalized estimating equations and negative binomial regression for catheter use over time and Cox proportional hazards models for mortality.

Results:

Creation of an AVF versus AVG placement was associated with greater catheter dependence at 1 month (95.6% vs 92.5%) and 3 months (82.8% vs 41.2%), but lower catheter dependence at 12 months (14.2% vs 15.8%) and 36 months (8.2% vs 15.0%). Creation of an AVF, however, remained significantly associated with 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%) after 3 years of follow-up.

Limitations:

Potential for unmeasured confounding and analyses limited to elderly patients.

Conclusions:

Creation of an AVF was associated with significantly greater cumulative catheter dependence than placement of an AVG in an elderly population initiating HD without a permanent access. As the long-term benefits in terms of catheter dependence of an AVF are not realized in many elderly patients, specific patient characteristics should be considered when making decisions regarding vascular access.

Keywords:

AVF maturation AVF placement Arteriovenous fistula (AVF)Fistula First arteriovenous graft (AVG)catheter dependence central venous catheter (CVC)elderly end-stage renal disease (ESRD)hemodialysis access short life expectancy vascular access

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