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Association Between Blood Cobalt Levels and Arteriovenous Fistula Dysfunction in Patients Undergoing Maintenance

Rui Hu¹, Qiangying Zeng¹, Xiao Xiao¹

¹Department of Nephrology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou City, Guangdong, China.

Kidney Medicine

|May 27, 2026

Insights

Elevated blood cobalt levels increase the risk of arteriovenous fistula (AVF) dysfunction in patients undergoing maintenance hemodialysis (MHD). This finding highlights the need for further research into cobalt

Area of Science:

Nephrology
Vascular Biology
Toxicology

Background:

Elevated cobalt concentrations in circulation are linked to endothelial inflammation and vascular dysfunction.
Maintenance hemodialysis (MHD) patients may experience increased cobalt levels due to various factors.
Arteriovenous fistulas (AVFs) are crucial for MHD patient survival, making AVF dysfunction a significant concern.

Purpose of the Study:

To investigate the association between blood cobalt levels and the incidence of AVF dysfunction in MHD patients.
To determine if elevated cobalt is an independent risk factor for AVF complications.

Main Methods:

A multicenter, observational cohort study involving 518 MHD patients.
Baseline whole-blood cobalt levels were measured using inductively coupled plasma mass spectrometry.
Patients were monitored for AVF dysfunction for up to 2 years, with dysfunction defined as blood flow reduction to ≤200 mL/min.

Main Results:

A total of 126 patients (24.3%) developed AVF dysfunction.
Patients with AVF dysfunction had significantly higher baseline blood cobalt concentrations.
The highest quartile of cobalt levels was associated with a 2.90-fold increased risk of AVF dysfunction (P < 0.001).

Conclusions:

Elevated blood cobalt levels are independently associated with an increased risk of AVF dysfunction in MHD patients.
Further research is needed to understand cobalt metabolism and its impact on AVF function for potential clinical interventions.

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Abstract

Rationale & Objective:

Prior studies have suggested that increased cobalt ion concentrations in circulation provoke inflammation in endothelial cells, disrupting vascular function. In patients undergoing maintenance hemodialysis (MHD), elevated cobalt may result from various factors. Given the critical role of arteriovenous fistulas (AVFs) in the survival of MHD patients, we aimed to investigate the relationship between cobalt levels and AVF dysfunction.

Study Design:

Multicenter, observational cohort study.

Setting & Study Populations:

A total of 518 patients undergoing maintenance hemodialysis at 3 medical centers.

Exposures:

Blood samples were collected before dialysis, and whole-blood cobalt levels were determined using inductively coupled plasma mass spectrometry.

Outcomes:

Blood cobalt concentrations were measured at baseline. Participants were monitored for AVF dysfunction, defined by a blood flow reduction to ≤200 mL/min during dialysis, and followed up to 2 years.

Analytical Approach:

Patients were divided into groups based on the occurrence of AVF dysfunction and analyzed using multivariable Cox regression, Kaplan-Meier curves, log-rank tests, restricted cubic spline analysis, and stratified analysis.

Results:

Of the 518 patients, 126 (24.3%) experienced AVF dysfunction within a median 16-month follow-up. Patients with AVF dysfunction exhibited significantly higher blood cobalt concentrations than did those without AVF dysfunction. The highest AVF dysfunction rate was observed in patients in the upper cobalt quartile (P < 0.001). Multivariable analysis indicated a 2.90-fold increased risk of AVF dysfunction in patients in the highest cobalt level quartile (P < 0.001). No significant interactions were observed in the stratified analyses (P > 0.05).

Limitations:

We only assessed the baseline cobalt levels at enrollment and did not perform serial measurements; we could not determine whether factors influencing trace element intake or absorption (eg, dietary habits or lifestyle) might have introduced temporal fluctuations in cobalt levels during follow-up, potentially influencing the results.

Conclusions:

Elevated blood cobalt levels were independently associated with an increased risk of AVF dysfunction in patients undergoing MHD. Further research on cobalt metabolism and its effects on AVF functionality to guide clinical interventions is required.

Keywords:

Blood cobalt levels arteriovenous fistula dysfunction maintenance hemodialysis risk factor

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