Abstract
In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) were included and analyzed retrospectively. The study outcome was defined as AVF patency and all-cause mortality (time to death). On Kaplan–Meier survival analysis, primary and secondary AVF patency rates did not differ significantly between the two groups (P = 0.812 and P = 0.586, respectively), although the overall survival rate was significantly higher in the pre-HD group compared with the on-HD group (P = 0.013). On multivariate analysis, well-known patient factors were associated with decreased primary (older age and diabetes mellitus [DM]) and secondary (DM and peripheral arterial occlusive disease) AVF patency, whereas use of a CVC as the initial predialysis access (hazard ratios, 1.84; 95% confidence intervals, 1.20–2.75; P = 0.005) was significantly associated with worse survival in addition to well-known patient factors (older age, diabetes mellitus, and peripheral arterial occlusive disease). Worse survival in the on-HD group was likely confounded by selection bias because of the retrospective nature of our study. Therefore, the observed lower mortality associated with AVF creation before HD initiation is not fully attributable to CVC use, but rather, affected by other patient-level prognostic factors. There were no CVC-related complications in the pre-HD group, whereas 10.2% of CVC-related complications were noted in the on-HD group. In conclusion, among incident HD patients, compared with patients who underwent creation of an AVF from a CVC, initial AVF creation showed similar primary and secondary AVF patency rates, but lower mortality risk. We also observed that an initial CVC use was an independent risk factor associated with worse survival. A fistula-first strategy might be the best option for incident HD patients who are good candidates for AVF creation.
Highlights
Fistula-first is the general recommendation for all hemodialysis (HD) patients [1,2,3]
A recent meta-analysis reported that nearly two-thirds of arteriovenous fistulas (AVFs) require the use of a bridging tunneled dialysis catheter while awaiting maturation, placing patients at increased risk of infection and that approximately 20% of AVFs are abandoned without use [4]
This study aimed to investigate whether AVF creation before HD initiation was associated with improved AVF patency compared with AVF creation after placement of a central venous catheter (CVC)
Summary
Fistula-first is the general recommendation for all hemodialysis (HD) patients [1,2,3]. A recent meta-analysis reported that nearly two-thirds of arteriovenous fistulas (AVFs) require the use of a bridging tunneled dialysis catheter (central venous catheter [CVC]) while awaiting maturation, placing patients at increased risk of infection and that approximately 20% of AVFs are abandoned without use [4]. This increased failure rate is associated with increased vascular access (VA)-related complications and procedures [5]. Timely creation of an AVF before HD initiation is not always feasible because of the unpredictability of renal failure progression and individual variation in maturation times; premature AVF creation is associated with increased risk of VA-related complications, whereas late AVF creation cannot prevent the need for the use of a CVC
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