Arteriovenous Vascular Access-Related Procedural Burden Among Incident Hemodialysis Patients in the United States

Am J Kidney Dis. 2021 Sep;78(3):369-379.e1. doi: 10.1053/j.ajkd.2021.01.019. Epub 2021 Apr 20.


Rationale & objective: As the proportion of arteriovenous fistulas (AVFs) compared with arteriovenous grafts (AVGs) in the United States has increased, there has been a concurrent increase in interventions. We explored AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis.

Study design: Observational cohort study.

Setting & participants: Patients initiating hemodialysis from July 1, 2012, to December 31, 2014, and having a first-time AVF or AVG placement between dialysis initiation and 1 year (N = 73,027), identified using the US Renal Data System (USRDS).

Predictors: Patient characteristics.

Outcome: Successful AVF/AVG use and intervention procedure burden.

Analytical approach: For each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modeling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase.

Results: During the maturation phase, 13,989 of 57,275 patients (24.4%) in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person. In the AVG group 2,904 of 15,572 patients (18.4%) required intervention during maturation, with therapeutic interventional requirements of 0.28 per person. During the maintenance phase, in the AVF group 12,732 of 32,115 patients (39.6%) required intervention, with a therapeutic intervention rate of 0.93 per person-year. During maintenance phase, in the AVG group 5,928 of 10,271 patients (57.7%) required intervention, with a therapeutic intervention rate of 1.87 per person-year. For both phases, the intervention rates for AVF tended to be higher on the East Coast while those for AVG were more uniform geographically.

Limitations: This study relies on administrative data, with monthly recording of access use.

Conclusions: During maturation, interventions for both AVFs and AVGs were relatively common. Once successfully matured, AVFs had lower maintenance interventional requirements. During the maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.

Keywords: Angioplasty; US Renal Data System (USRDS); arteriovenous fistula (AVF); arteriovenous graft (AVG); assisted maturation; dialysis access; end-stage renal disease (ESRD); endovascular interventions; hemodialysis (HD); patency; regional procedure variation; thrombectomy; vascular access.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Arteriovenous Shunt, Surgical / adverse effects*
  • Female
  • Follow-Up Studies
  • Graft Occlusion, Vascular / epidemiology*
  • Graft Occlusion, Vascular / etiology
  • Graft Occlusion, Vascular / physiopathology
  • Humans
  • Incidence
  • Kidney Failure, Chronic / therapy
  • Male
  • Middle Aged
  • Renal Dialysis / adverse effects*
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • United States / epidemiology
  • Vascular Patency / physiology*
  • Young Adult