Impact of Body Mass Index on Outcomes of Autogenous Fistulas for Hemodialysis Access

Abstract

The prevalence of obesity is increasing in the United States. The treatment of end-stage renal disease (ESRD) via hemodialysis spans the spectrum of body mass index (BMI). This study examines the impact of BMI on outcomes of autogenous fistulas for hemodialysis access in a large population-based cohort of patients. A retrospective study of all patients in the prospectively maintained United States Renal Database System who initiated hemodialysis between 2007 and 2014 was performed. Chi-squared test, t-tests, Kaplan-Meier estimates, log-rank tests, multivariable logistic and Cox regression analysis were employed to evaluate access maturation, interventions, patency, and mortality. There were 300,778 patients studied. Of these, 9,394 (3.1%) were underweight, 87,351 (29.1%) were normal weight, 86,101 (28.6%) were overweight, 57,047 (19%) were obese class I, 31,077 (10.3%) were obese class II, and 29,808 (9.9%) were obese class III. There was no significant difference in maturation for patients who were underweight (adjusted hazard ratio [aHR] 0.97, 95% CI 0.89-1.06, P=0.48), overweight (aHR 1.01, 95% CI 0.97-1.05, P=0.66), obese class I (aHR 1.05, 95% CI 0.99-1.09, P=0.22), or obese class II (aHR 1.01, 95% CI 0.94-1.05, P=0.98 relative to normal weight. However, there was a 6% decrease in maturation for obese class III patients (aHR 0.94, 95% CI 0.89-0.99, P=0.02) compared to normal weight patients. Primary (aHR 0.93, 95% CI 0.91-0.96, P<0.001), primary assisted (aHR 0.90, 95% CI 0.88-0.93, P<0.001), and secondary patency (aHR 0.89, 95% CI 0.86-0.92, P<0.001) were lower for underweight compared to normal weight patients. There was 8%, 10%, and 7% decrease in primary (aHR 0.92, 95% CI 0.90-0.93, P<0.001), primary assisted (aHR 0.90, 95% CI 0.88-0.92, P<0.001), and secondary patency (aHR 0.93, 95% CI 0.91-0.94, P<0.001) respectively for patients in obese class III compared to patients with normal weight. There was an increase in patient survival with increasing BMI. In this population-based cohort of hemodialysis-dependent patients, severe obesity was associated with a decrease in fistula maturation. Extremes of BMI were associated with lower patency, but higher BMI was associated with better patient survival. Obese patients nearing ESRD might require earlier referral for arteriovenous fistula (AVF) placement in order to allow for maturation and AVF use at incident hemodialysis.