Predialysis Vascular Access Placement and Catheter Use at Hemodialysis Initiation

Abstract

Background Current guidelines encourage placement of an arteriovenous (AV) fistula in patients with advanced chronic kidney disease to avoid initiation of hemodialysis with a central venous catheter. However, the relative merits of pre-dialysis placement of an AV fistula or graft has been poorly studied. Methods The current study included 380 patients (mean age 59 ± 14 years, 73% Black patients, 51% male) from a large academic medical center who underwent pre-dialysis placement of an AV fistula (286) or AV graft (94). The study quantified three endpoints: time from access placement to initiation of dialysis, likelihood of starting hemodialysis without a catheter, and number of vascular access procedures prior to dialysis initiation. Results The eGFR at access surgery was <10, 10-14 and >15 ml/min/1.73 m2 in 87 (23%), 179 (47%) and 114 (30%) patients, respectively. The median time from access surgery to hemodialysis initiation was 69, 156, and 429 days in patients with an eGFR of <10, 10-14 and >15 ml/min/1.73 m2, respectively (p<0.001). Hemodialysis was initiated within 2 years of access surgery in 298 (78%) of the patients. Catheter-free hemodialysis initiation was higher in patients with an AV graft vs an AV fistula when the eGFR was <10 ml/min/1.73 m2 [88 vs 43%; OR 9.10, (95% CI 2.74-26.4)] and when the eGFR was 10-14 ml/min/1.73 m2 [88 vs 54%; OR 6.05 (2.35-15.0)], but similar when the eGFR was >15 ml/min/1.73 m2 [90 vs 75%; OR 3.00 (0.48-34.9)]. Patients undergoing an AV fistula were more likely to undergo an angioplasty (11 vs 0%, p<0.001), surgical access revision (26 vs 8%, p<0.001), a second access placement (16 vs 6%, p=0.02), and a catheter insertion (32 vs 11%, p<0.001). Conclusions Among patients with chronic kidney disease undergoing vascular access surgery when their eGFR was <15 ml/min/1.73 m2, catheter use at dialysis initiation was much less likely when an AV graft, rather than an AV fistula, was placed.

A Requiem for Fistula First

“…We analyzed a cohort of 380 patients undergoing pre-ESKD access surgery at a single center. 11 The median time from access placement to dialysis initiation was 69, 156, and 429 days in patients with an eGFR ,10, 10-14, and $15 ml/min per 1.73 m 2 , respectively. Among those with AV fistula placement, the likelihood of catheter-free hemodialysis initiation was progressively higher (43%, 54%, and 75%) when the eGFR at the time of surgery was ,10, 10-14, and $15 ml/min per 1.73 m 2 , respectively.…”

Right Access at the Right Time

“…1 In this issue of CJASN, Allon et al retrospectively reviewed a sizable cohort of patients with CKD from a prospectively collected database spanning 7 years (2013-2019). 2 They compared the outcomes of AV fistula (75%) with AV graft (25%) constructed before HD in patients with CKD. They evaluated the time taken from access placement to HD initiation, the likelihood of starting HD with a CVC, and the number of access procedures before starting HD.…”