Arteriovenous Fistula Use Is Associated with Lower Cardiovascular Mortality Compared with Catheter Use among ESRD Patients

Abstract

The arteriovenous fistula (AVF) is the recommended form of dialysis vascular access, however, limited studies suggest that AVF creation may result in increased cardiovascular stress and remodeling. To explore the contribution of vascular access type to cardiovascular-related (CV) mortality, we analyzed USRDS Clinical Performance Measures data comprising 4854 patients that initiated dialysis between October 1, 1999-December 31, 2004. CV mortality included death from acute myocardial infarction, atherosclerotic heart disease, cardiomyopathy, arrhythmia, cardiac arrest or stroke. Risk of cardiovascular mortality during a 4-year observation was analyzed by Coxregression methods with adjustments for demographic and co-morbid conditions. AVF use was strongly associated with lower all-cause and CV mortality. After adjustment for covariates, AVF use 90 days after dialysis initiation remained significantly associated with lower cardiovascular mortality [hazard ratio (HR) 0.69, p = 0.0004] compared with catheter use. These findings suggest that vascular access type influences cause-specific mortality beyond that of infection, and support existing guidelines recommending the use of an AVF early in the course of chronic end-stage renal disease therapy.Cardiovascular disease (CVD) is the primary cause of mortality among end-stage renal disease (ESRD) patients (1). Arteriovenous fistulae (AVF) confer protection against sepsis and allcause mortality and are the recommended form of vascular access for hemodialysis patients, compared with arteriovenous grafts (AVG) or central venous catheters (CVC) (2-4). However, it is unknown whether an AVF is associated with increased cardiovascular-related (CV) mortality. Limited reports suggest that AVF creation is associated with hemodynamic changes that impose immediate cardiovascular effects which increase cardiac workload, resulting in left ventricular hypertrophy, the progression of which is associated with CV morbidity, mortality, and all-cause death (5-11).As an increasing proportion of dialysis patients undergo AVF creation, it is critical to better understand the impact of AVF use on CV-related outcomes in order to help guide clinical decision-making prior to dialysis initiation. We have previously described predictors of delayed transition to permanent vascular access among incident hemodialysis patients and extend these observations here to focus on the impact of initial and delayed vascular access type on CV-related mortality (12). We hypothesized that AVF use at dialysis initiation would be associated with increased CV-related mortality, and tested this hypothesis in a contemporary, national cohort of incident hemodialysis patients. Demographic and co-morbid characteristics used in our analysis included age (<54.6, 54.6 to <65.8, 65.8 to <74.5, ≥74.5), gender, race (black, white), pre-ESRD albumin (<3.5 mg/dl, ≥3.5 mg/dl), pre-ESRD hemoglobin (<11 g/dl, ≥11 g/dl), pre-ESRD erythropoietin (yes, no), body mass index (BMI, kg/m 2 ) was classified according to the World Hea...

Associations between Hemodialysis Access Type and Clinical Outcomes

“…15 In addition, chronically colonized surface biofilm in synthetic access-related material may increase the risk of cardiovascular disease in persons on hemodialysis by inflammation. 16 In support of this hypothesis, we found that use of grafts and catheters was associated with stronger risks of infection and hospitalization compared with fistulas. The proportion of access-related fatal infections in available studies was not reported, and in one study, only 23% of all infectionrelated hospitalizations were considered directly caused by access infection, 17 suggesting that catheter and graft colonization does not entirely explain the increased Figure 3.…”

Synthetic Vascular Hemodialysis Access Versus Native Arteriovenous Fistula

“…AVF use 90 days after dialysis initiation is associated with lower cardiovascular mortality 35 . Several authors have demonstrated that increasing the use of AVF in incident dialysis patients is possible in the US 36, 37 .…”

Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis

“…Several studies have reported morbidity and mortality benefits of AVF compared with AVG and TCC (23,24). However, octogenarians are a vulnerable patient group and data regarding their outcomes after AVF surgery are conflicting.…”