Haemodialysis Access-Induced Distal Ischaemia After Upper Limb Arteriovenous Access Formation

Haemodialysis access-induced distal ischaemia (HAIDI) is an uncommon but potentially disabling complication of upper-limb vascular access (VA) formation. Incidence estimates vary widely, and long-term risk in New Zealand's ethnically diverse population has not previously been described. We aimed to define the incidence, natural history, risk factors, and outcomes of HAIDI in a contemporary New Zealand cohort.

This retrospective multicentre cohort study included all adults undergoing upper-limb VA formation between January 2020 and December 2024 at three public hospitals serving approximately 35% of New Zealand's population. Patients were identified using the Australasian Vascular Audit, with data extracted from electronic medical records. Time-to-event analyses and multivariable Cox regression were used to describe HAIDI risk and identify independent predictors, including ethnicity-associated differences.

Among 799 patients, mean age was 55.9 years, 60.3% were male, 70.5% had diabetes, 49.9% were Pacific peoples, and 24.2% were Māori. Over a median follow-up of 3.0 years, 46 patients developed HAIDI, corresponding to a five-year cumulative risk of 6.6%. Events most commonly occurred months after access formation and continued to accrue over time. Independent risk factors were diabetes, peripheral arterial disease, and upper-arm VA configuration. Māori ethnicity was associated with HAIDI in initial adjusted analyses, but this was attenuated after adjustment for measured comorbidity and access-related factors.

In this Aotearoa New Zealand cohort with high Māori and Pacific representation, HAIDI occurred in approximately one in fifteen patients and frequently required intervention. These findings support integrating comorbidity assessment into VA selection, distal-first planning where feasible, and long-term education and surveillance for delayed HAIDI symptoms.