Characterization of Long-term Survival in Medicare Patients Undergoing Arteriovenous Hemodialysis Access

Abstract

Patients undergoing arteriovenous (AV) access creation for hemodialysis (HD) often have significant comorbidities. Our goal was to quantify the long-term survival and associated risk factors for long-term mortality in these patients to aid in optimization of goals and expectations. The Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Vascular Quality Initiative Medicare–linked data were used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. As the majority of HD patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality. A total of 13,945 AV access patients were analyzed: 10,872 (78%) AV fistulas and 3073 (22%) AV grafts. Patients receiving an AV fistula were more often younger, male, White, obese, independently ambulatory, preoperatively living at home, have fewer comorbidities, and less often have a prior AV access and tunneled dialysis catheters (P < .05 for all). The 5-year mortality overall was 62.9%, with 61.2% for AV fistulas and 68.8% for AV grafts (P < .001). On multivariable analysis, nonambulatory status (hazard ratio [HR]: 1.67, 95% confidence interval [CI]: 1.53-1.83; P < .0001), lower extremity access (HR: 1.67, 95% CI: 1.35-2.05; P < .0001), HIV/AIDS (HR: 1.44, 95% CI: 1.13-1.82; P = .003), White race (HR: 1.43, 95% CI: 1.35-1.51; P < .0001), current smoking (HR: 1.38, 95% CI: 1.27-1.49; P < .0001), congestive heart failure (HR: 1.33, 95% CI: 1.26-1.41; P < .0001), chronic obstructive pulmonary disease (HR: 1.23, 95% CI: 1.15-1.31; P < .0001), and AV graft placement (HR: 1.12, 95% CI: 1.02-1.23; P = .016) were associated with poor survival. Long-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. Further research focusing on modifiable risk factors in this population is warranted.