Clinical significance of maturing vascular access for incident hemodialysis patients

Reliable vascular access is required for hemodialysis (HD). Central venous catheters (CVC) can be used immediately, but are traditionally associated with increased mortality compared to arteriovenous fistulas or grafts (AVF/AVG). Immature fistulas or grafts may or may not become usable; their impact on long-term mortality or transplant has not been defined.

Adult incident HD patients entering the United States Renal Data System between 1/2018 and 12/2019 were identified, and included if still on HD at day 90. Initial dialysis accesses were categorized as mature AVF/AVG, CVC-only, or CVC with an fistula or graft that was not ready for use (CVC-plus). Cox models were used to examine the associations between access type and patient mortality, and logistic models for kidney transplant waitlist appearance, using propensity-matched samples. CVC-plus was the reference group for all models.

Among 214,673 patients, 66% had CVC-only, 15% CVC-plus, and 19% AVF/AVG. Over median follow up of 30 months, 45% died and 5% received kidney transplants. Compared to patients with CVC-plus, having CVC-only was associated with increased death (HR = 1.31, 95% CI = 1.29-1.35, p < 0.001) but similar rates of kidney transplantation (HR = 1.01, 95% CI = 0.97-1.14, p = 0.20), despite more waitlisting. Having AVF/AVG was associated with decreased death (HR = 0.81, 95% CI = 0.79-0.83) and increased transplantation (HR = 1.39, 95% CI = 1.30-1.50), p < 0.001 for both.

Initiating HD with CVC-plus was advantageous compared to CVC-only, but outcomes were inferior to those of patients initiating HD with mature AVF/AVG.