Tradeoffs in Vascular Access Selection in Elderly Patients Initiating Hemodialysis With a Catheter

Am J Kidney Dis. 2018 Oct;72(4):509-518. doi: 10.1053/j.ajkd.2018.03.023. Epub 2018 May 18.


Rationale & objective: National vascular access guidelines recommend placement of arteriovenous fistulas (AVFs) over grafts (AVGs) in hemodialysis patients, but have not been comprehensively assessed in the elderly. We evaluated clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation.

Study design: Retrospective cohort study using national administrative data.

Settings & partcipants: Claims data from the US Renal Data System of 9,458 US patients 67 years and older who initiated hemodialysis therapy from July 1, 2010, to June 30, 2011, with a catheter and received an AVF (n=7,433) or AVG (n=2,025) within the ensuing 6 months.

Predictor: Arteriovenous access subtype, AVF or AVG.

Outcomes: Successful use of vascular access, interventions to make vascular access functional, duration of catheter dependence before successful use of vascular access, frequency of interventions, and abandonment after successful use of vascular access.

Analytical approach: Multivariable logistic regression analysis was used to compare the need for intervention before successful use of AVFs and AVGs, and negative bionomial regression was used to calculate the frequency of intervention after successful use of vascular access.

Results: Unsuccessful use of vascular access within 6 months of creation was higher for AVFs versus AVGs (51% vs 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99). Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs 23%; OR, 2.66; 95% CI, 2.26-3.12). AVFs had a lower 1-year abandonment rate after successful use compared with AVGs (OR, 0.71; 95% CI, 0.62-0.83) and required one-fourth fewer interventions after successful use (relative risk, 0.75; 95% CI, 0.69-0.81). Patients receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs 1 month; P<0.001).

Limitations: Residual confounding due to vascular access choice, restriction to an elderly population, and 1-year follow-up period.

Conclusions: In elderly hemodialysis patients initiating hemodialysis therapy with a catheter, the optimal vascular access selection depends on tradeoffs between shorter catheter dependence and less frequent interventions to make the vascular access (AVG) functional versus longer access patency and fewer interventions after successful use of the vascular access (AVF).

Keywords: End-stage renal disease (ESRD); Fistula First; angioplasty; arteriovenous fistula (AVF); arteriovenous graft (AVG); catheter dependence; central venous catheter (CVC); dialysis initiation; elderly; hemodialysis (HD); interventions; patency; renal replacement therapy (RRT); vascular access.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Arteriovenous Shunt, Surgical / adverse effects*
  • Catheterization / adverse effects
  • Catheterization / methods
  • Cohort Studies
  • Databases, Factual
  • Female
  • Follow-Up Studies
  • Geriatric Assessment
  • Graft Occlusion, Vascular / epidemiology*
  • Humans
  • Kaplan-Meier Estimate
  • Kidney Failure, Chronic / diagnosis
  • Kidney Failure, Chronic / mortality
  • Kidney Failure, Chronic / therapy*
  • Male
  • Multivariate Analysis
  • Patient Safety
  • Renal Dialysis / adverse effects
  • Renal Dialysis / methods*
  • Retrospective Studies
  • Risk Assessment
  • Time Factors
  • Treatment Outcome
  • United States
  • Vascular Access Devices / adverse effects*
  • Vascular Patency / physiology*