New-Onset Heart Failure in Hemodialysis Patients: Association With Access Location and Access Flow in a Nationwide...

There is increasing evidence that arteriovenous fistulas (AVFs) might alter cardiac function. Upper arm AVFs are associated with higher access flow, and their use is increasing. It has been hypothesized that the creation of upper arm AVFs would lead to a higher incidence of heart failure compared with forearm AVFs.

Retrospective cohort study.

All patients who received a hemodialysis access between 2013 and 2022 in Sweden. Patients with prevalent heart failure or previous hemodialysis were excluded.

Type of hemodialysis access and access flow.

New-onset heart failure.

Cox proportional hazards regression for type of access and restricted cubic splines for access flow. Comorbid conditions were included as covariates in both models.

In total, 10,170 patients were included. Of those, 6,579 patients with a total of 11,238 accesses remained after excluding patients with prevalent heart failure or prevalent hemodialysis. The risk of new-onset heart failure was comparable between forearm and upper arm AVF (P = 0.57). Access flow was highest in upper arm AVF (P < 0.001), but there was a substantial overlap. The risk of heart failure development depending on access flow was nonlinear (P < 0.001) with increased risk in patients with lowest as well as the highest flow.

Reliance on International Classification of Diseases (ICD)-10 codes is a limitation because of potential underascertainment and misclassification. The findings may not be generalizable to settings where upper arm AVF are used more liberally than in Sweden.

Upper arm AVFs were not associated with the development of heart failure. Comorbid conditions such as ischemic heart disease, heart valve disease, and diabetes as well as age were more important factors for the development of heart failure than access type. The association between access flow and new-onset heart failure is U-shaped.