Arteriovenous Fistula Placement, Maturation, and Patency Loss in Older Patients Initiating Hemodialysis

Am J Kidney Dis. 2020 Oct;76(4):480-489.e1. doi: 10.1053/j.ajkd.2020.02.449. Epub 2020 Jul 9.


Rationale & objective: The current clinical guidelines for vascular access do not have specific recommendations for older hemodialysis patients. Our study aimed to determine the association of age with arteriovenous fistula (AVF) placement, maturation, and primary and secondary patency loss among older hemodialysis recipients.

Study design: Retrospective cohort study.

Setting & participants: A US national cohort of incident hemodialysis patients 67 years or older (N = 43,851) assembled from the US Renal Data System.

Exposure: Age at dialysis initiation.

Outcomes: AVF placement, maturation, primary patency loss, and abandonment.

Analytical approach: Cause-specific and subdistribution proportional hazards models were used to examine the association of age and AVF outcomes, with kidney transplantation, peritoneal dialysis, and death treated as competing events. Age cutoff was identified by restricted cubic splines. We compared crude and inverse probability-weighted cumulative incidence functions using Gray's test.

Results: As compared with those aged 67-<77 years, patients 77 years or older had significantly lower probabilities of AVF placement (adjusted cause-specific HR [cHR], 0.96 [95% CI, 0.92-0.99]; adjusted subdistribution HR [sHR], 0.92 [95% CI, 0.89-0.95]; Gray's test P < 0.001) and maturation (adjusted cHR, 0.95 [95% CI, 0.91-0.99]; adjusted sHR, 0.93 [95% CI, 0.90-0.97]; P < 0.001). However, age was not associated with AVF primary (adjusted cHR, 1.05 [95% CI, 1.00-1.11]; adjusted sHR, 1.04 [95% CI, 0.99-1.09]; P = 0.09) or secondary (adjusted cHR, 1.06 [95% CI, 0.94-1.20]; adjusted sHR, 1.05 [95% CI, 0.93-1.18]; P = 0.4) patency loss.

Limitations: Reliance on administrative claims to ascertain AVF outcomes.

Conclusions: The likelihood of AVF maturation is an important consideration for vascular access planning. Age alone should not be the basis for excluding older dialysis patients from AVF creation because maintenance of fistula patency was not reduced with older age despite a modest reduction in fistula maturation.

Keywords: AVF outcome; Hemodialysis; age; arteriovenous fistula (AVF); competing risks; elderly; end-stage renal disease (ESRD); individualized treatment plan; maturation; older adults; patency; placement; survival analysis; vascular access.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Arteriovenous Shunt, Surgical* / adverse effects
  • Cohort Studies
  • Female
  • Humans
  • Male
  • Renal Dialysis*
  • Retrospective Studies
  • Vascular Patency