The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

Abstract

Background: Several studies report lower costs associated with attaining and maintaining patency for arteriovenous (AV) fistulas as compared to AV-grafts among hemodialysis patients. However, these costs may vary according to the AV-access's risk of failure to mature (FTM). To analyze the impact of AV-access type and risk of FTM on the total costs of attaining and maintaining Av-access patency over one, three, and five years post creation, among incident accesses.Methods: All first AV-access creations (January 1, 2002 -January 1, 2018), revisions/resections, and interventions from a single academic institution were prospectively captured. The units costs (2011 CAD) were estimated primarily through the provincial patient Ontario Case Costing Initiative database. The present value of total vascular access related costs from a third party payer perspective was calculated by multiplying specific unit costs by the number of AV-access creations, revisions/resections and interventions from the date of creation to one-, three-, and five-post creation. The potential associations of AV-access type and FTM risk stratum with AV-access cost were examined using Loglinear models and generalized estimating equations.Results: A total of 906 patients were included in the study, 696 fistulas and 210 grafts. The median present value of total costs to attain and maintain AV-access over one, three, and five years was positively associated with the highest FTM risk stratum in all models. It was not associated with AV-access type when the interaction between AV-access type and FTM risk stratum was considered. Conclusions:The costs of attaining and maintaining AV-access were increased among patients with high/very high FTM risk. Risk of FTM, related interventions and costs should be considered when choosing vascular access type for an individual patient. BackgroundFor adequate hemodialysis, a reliable vascular access is essential and remains the "Achille's Heel" of hemodialysis. The United States' national quality initiative to improve vascular access outcomes, originally called "Fistula First", was based on the perception that arteriovenous (AV) fistulas have superior patency, the fewest complications and are less costly compared with other vascular access types (1, 2). Indeed, catheters have been established as associated with the highest rates of complications, particularly infection (3-10), although they are often needed as a temporary measure, such as until an AV-access (fistula or graft) can be created and used, or as a valid long-term option in select circumstances (11,12). The validity of Fistula First has been recently been challenged in comparisons of outcomes of fistulas and grafts (12)(13)(14)(15)(16).A systematic review of observational studies comparing clinical outcomes between fistulas and grafts found that the former is associated with high rates of maturation failure but longer-term patency, while the latter is more likely to mature and mature quickly, but with shorter patency (17). The review noted that the included st...

Comparing post-maturation outcomes of arteriovenous grafts and fistulae

“…22 Failure to mature and patency loss require patients to restart the process of access creation and are associated with excessive costs. 23,24 Grafts can be cannulated shortly after creation, but 1-year primary patency rates, are low, commonly documented between 48 to 54% however can be as low as 20%. [25][26][27] Almost a fifth of grafts will require interventions before cannulation.…”

Reproducibility in Research: The Role of Kidney360

“…Immune checkpoint inhibitors may cause acute interstitial nephritis 13 Remote monitoring of patients on peritoneal dialysis reduces hospitalizations and technique failure 14 Arteriovenous failure to mature increases access-related costs in hemodialysis patients 15 Scintigraphy is a simple and reliable tool to diagnose PD fluid leaks 16 Hypoglycemia is common in patients with diabetes and chronic kidney disease 17 Functional patency was similar for arteriovenous fistulas and grafts, but the latter required more frequent interventions to maintain access patency 18 Hemodialysis patient mortality is increased in patients with PTH levels .450 or ,350 pg/ml 19 Nondiabetic kidney disease is identified frequently in diabetic patients undergoing a kidney biopsy 20 Arteriovenous failure is more common in hemodialysis patients who are female, have a lower diastolic blood pressure, or who have a central vein catheter 21 Tonsillectomy is associated with slower progression of kidney disease in patients with IgA nephropathy 22 Patients with COVID-19 requiring ICU admission had a high rate of AKI and mortality 23 In patients hospitalized with COVID-19 and severe AKI requiring CRRT, there is a high frequency of loss of patency of the dialysis circuit due to thrombosis 24 In patients with advanced CKD, the rate of decline of kidney function is slower after creation of an arteriovenous fistula 25 An unhealthy diet is associated with a faster decline of kidney function 26 A faster decline in kidney function is associated with higher mortality and cardiovascular events 27 In patients with focal glomerular sclerosis, a higher risk of end-stage kidney disease is associated with nephrotic range proteinuria, hypoalbuminemia, interstitial fibrosis and tubular atrophy, and absence of remission 28 Acute tubular necrosis is a common kidney biopsy finding in patients with COVID-19 and acute kidney injury 29 The use of an arteriovenous fistula or graft at initiation of hemodialysis varies greatly among dialysis centers 30 A high proportion of patients initiate hemodialysis with a central vein catheter, and a sizable proportion is still catheter-dependent after 1 year 31 The "surprise question" is highly predictive of 1-year mortality in patients with advanced chronic kidney disease 32 Post-transplant diabetes is common and associated with older age and obesity 33 Bleeding complications after a kidney biopsy are more common in female patients 34 The immune response to the COVID-19 vaccine is impaired in dialysis and kidney transplant patients…”

Tailoring Vascular Access for Dialysis: Can Frailty Assessment Improve the Fit?

“…Applying frailty assessments may allow us to better identify individuals who may or may not benefit from a particular access creation type, or have access creation at all where the high risk of failure to mature comes with extra cost in attaining and maintaining the access. 13 A challenge with such an approach is identifying the optimal method for frailty assessment and screening. Multiple tools exist based predominantly on the Fried Phenotype or the Frailty Index, with no current consensus on which tool is the best to use.…”