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

Abstract

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. Retrospective cohort study. A US national cohort of incident hemodialysis patients 67 years or older (N= 43,851) assembled from the US Renal Data System. Age at dialysis initiation. AVF placement, maturation, primary patency loss, and abandonment. 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. 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) andmaturation (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. Reliance on administrative claims to ascertain AVF outcomes. 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.