The Effect of Predialysis Fistula Attempt on Risk of All-Cause and Access-Related Death

Abstract

Whether the lower risk of mortality associated with arteriovenous fistula use in hemodialysis patients is due to the avoidance of catheters or if healthier patients are simply more likely to have fistulas placed is unknown. To provide clarification, we determined the proportion of access-related deaths in a retrospective cohort study of patients aged $18 years who initiated hemodialysis between 2004 and 2012 at five Canadian dialysis programs. A total of 3168 patients initiated dialysis at the participating centers; 2300 met our inclusion criteria. Two investigators independently adjudicated cause of death using explicit criteria and determined whether a death was access-related. We observed significantly lower mortality in individuals who underwent a predialysis fistula attempt than in those without a predialysis fistula attempt in patients aged ,65 years (hazard ratio [HR], 0.49; 95% confidence interval [95% CI], 0.29 to 0.82) and in the first 2 years of follow-up in those aged $65 years (HR 0-24 months , 0.60; 95% CI, 0.43 to 0.84; HR 24+ months , 1.83; 95% CI, 1.25 to 2.67). Sudden deaths that occurred out of hospital accounted for most of the deaths, followed by deaths due to cardiovascular disease and infectious complications. We found only 2.3% of deaths to be access-related. In conclusion, predialysis fistula attempt may associate with a lower risk of mortality. However, the excess mortality observed in patients treated with catheters does not appear to be due to direct, access-related complications but is likely the result of residual confounding, unmeasured comorbidity, or treatment selection bias.

The Interdisciplinary Chronic Kidney Disease Clinic: End of the Beginning, Not Beginning of the End

“…This finding adds to the recent studies by Quinn et al [2] and Brown et al [3] that propose a more nuanced view of the optimal care of patients with chronic kidney disease (CKD) stages 4 and 5. In these studies, patients who underwent an ultimately non-successful AVF placement and initiated dialysis with a hemodialysis catheter had improved mortality compared to those who had initiated dialysis with a catheter and had yet not undergone AVF construction.…”

“…In these studies, patients who underwent an ultimately non-successful AVF placement and initiated dialysis with a hemodialysis catheter had improved mortality compared to those who had initiated dialysis with a catheter and had yet not undergone AVF construction. These findings imply that it is not solely the vascular access itself but also the prosecution of pre-ESRD nephrology care for greater than 12 months that provides an equal portion of the survival advantage following the onset of dialysis.The results of Quinn et al [2] and Brown et al[3] augment and complement the growing body of literature that demonstrates the benefits of pre-ESRD nephrology care, particularly in the form of an interdisciplinary CKD clinic. Pre-ESRD nephrology education using an interdisciplinary approach results in more patients beginning dialysis at home, and also leads to a greater percentage of patients with a permanent access when in-center hemodialysis is chosen [4] .…”

Dialysis Access as an Area of Improvement in Elderly Incident Hemodialysis Patients: Results from a Cohort Study from the International Monitoring Dialysis Outcomes Initiative

“…Particularly with regard to possible expectations by caregivers that many patients may die before they reach dialysis or soon thereafter, there is some hesitancy to prepare elderly patients early for dialysis [8]. However, while not significant in the elderly population older than 65 years, data suggest that predialysis fistula attempts confer a survival benefit in incident hemodialysis (HD) patients [9]. The authors conclude that the excess mortality observed in patients treated with catheters may not be directly access related but the result of residual confounding, unmeasured comorbidity, or a treatment selection bias [9].…”

“…However, while not significant in the elderly population older than 65 years, data suggest that predialysis fistula attempts confer a survival benefit in incident hemodialysis (HD) patients [9]. The authors conclude that the excess mortality observed in patients treated with catheters may not be directly access related but the result of residual confounding, unmeasured comorbidity, or a treatment selection bias [9]. This interpretation may also explain the lack of a significant survival benefit in the elderly fraction (i.e., older than 65 years) [9].…”

Pre-End-Stage Renal Disease Care and Early Survival among Incident Dialysis Patients in the US Military Health System

“…In a retrospective cohort study of 2,300 patients at 5 Canadian dialysis programs, Quinn et al [40] reported that patients who underwent a predialysis fistula attempt had a lower mortality risk than those who did not. However, only 2.3% of deaths were access related; thus, the excess mortality in patients with catheters did not appear to be causally related to the catheters but may instead reflect underlying poor clinical status.…”