Rationale & objective: Creation of an arteriovenous fistula (AVF), compared with an arteriovenous graft (AVG), is associated with longer initial catheter dependence after starting hemodialysis (HD) but longer access survival and lower long-term catheter dependence. The extent of these potential long-term benefits in elderly patients is unknown. We assessed catheter dependence after AVF or AVG placement among elderly patients who initiated HD without a permanent access in place.
Study design: Retrospective cohort study.
Setting & participants: Patients≥67 years of age identified in the US Renal Data System who had a first AVF (n=14,532) or AVG (n=3,391) placed within 1 year after HD initiation between May 2012 and May 2017.
Exposure: AVF versus AVG placement in the first year of HD.
Outcome: Catheter dependence after AVF or AVG placement assessed using CROWNWeb data.
Analytical approach: Generalized estimating equations and negative binomial regression for catheter use over time and Cox proportional hazards models for mortality.
Results: Creation of an AVF versus AVG placement was associated with greater catheter dependence at 1 month (95.6% vs 92.5%) and 3 months (82.8% vs 41.2%), but lower catheter dependence at 12 months (14.2% vs 15.8%) and 36 months (8.2% vs 15.0%). Creation of an AVF, however, remained significantly associated with greater cumulative catheter-dependent days (80.1 vs 54.6 days per person-year) and a lower proportion of catheter-free survival time (78.1% vs 85.1%) after 3 years of follow-up.
Limitations: Potential for unmeasured confounding and analyses limited to elderly patients.
Conclusions: Creation of an AVF was associated with significantly greater cumulative catheter dependence than placement of an AVG in an elderly population initiating HD without a permanent access. As the long-term benefits in terms of catheter dependence of an AVF are not realized in many elderly patients, specific patient characteristics should be considered when making decisions regarding vascular access.
Keywords: AVF maturation; AVF placement; Arteriovenous fistula (AVF); Fistula First; arteriovenous graft (AVG); catheter dependence; central venous catheter (CVC); elderly; end-stage renal disease (ESRD); hemodialysis access; short life expectancy; vascular access.
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