American Journal of Kidney Diseases

Arteriovenous Fistula Placement, Maturation, and Patency Loss in Older Patients Initiating Hemodialysis

  • Joyce Z. Qian
    Address for Correspondence: Joyce Z. Qian, PhD, Medical Technology and Practice Patterns Institute (MTPPI), 5272 River Rd, Ste 665, Bethesda, MD 20816.
    Medical Technology and Practice Patterns Institute, Bethesda, MD

    Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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  • Mara McAdams-DeMarco
    Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD

    Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
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  • Derek K. Ng
    Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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  • Bryan Lau
    Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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      Rationale & Objective

      The current clinical guidelines for vascular access do not have specific recommendations for older hemodialysis patients. Our study aimed to determine the association of age with arteriovenous fistula (AVF) placement, maturation, and primary and secondary patency loss among older hemodialysis recipients.

      Study Design

      Retrospective cohort study.

      Setting & Participants

      A US national cohort of incident hemodialysis patients 67 years or older (N = 43,851) assembled from the US Renal Data System.


      Age at dialysis initiation.


      AVF placement, maturation, primary patency loss, and abandonment.

      Analytical Approach

      Cause-specific and subdistribution proportional hazards models were used to examine the association of age and AVF outcomes, with kidney transplantation, peritoneal dialysis, and death treated as competing events. Age cutoff was identified by restricted cubic splines. We compared crude and inverse probability–weighted cumulative incidence functions using Gray's test.


      As compared with those aged 67-<77 years, patients 77 years or older had significantly lower probabilities of AVF placement (adjusted cause-specific HR [cHR], 0.96 [95% CI, 0.92-0.99]; adjusted subdistribution HR [sHR], 0.92 [95% CI, 0.89-0.95]; Gray's test P < 0.001) and maturation (adjusted cHR, 0.95 [95% CI, 0.91-0.99]; adjusted sHR, 0.93 [95% CI, 0.90-0.97]; P < 0.001). However, age was not associated with AVF primary (adjusted cHR, 1.05 [95% CI, 1.00-1.11]; adjusted sHR, 1.04 [95% CI, 0.99-1.09]; P = 0.09) or secondary (adjusted cHR, 1.06 [95% CI, 0.94-1.20]; adjusted sHR, 1.05 [95% CI, 0.93-1.18]; P = 0.4) patency loss.


      Reliance on administrative claims to ascertain AVF outcomes.


      The likelihood of AVF maturation is an important consideration for vascular access planning. Age alone should not be the basis for excluding older dialysis patients from AVF creation because maintenance of fistula patency was not reduced with older age despite a modest reduction in fistula maturation

      Graphical abstract

      Index Words

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        • Saran R.
        • Robinson B.
        • Abbott K.C.
        • et al.
        US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2019; 73: A7-A8
        • Collins A.J.
        • Foley R.N.
        • Herzog C.
        • et al.
        US Renal Data System 2012 annual data report.
        Am J Kidney Dis. 2013; 61: e1-e480
        • Cook W.L.
        • Jassal S.V.
        Functional dependencies among the elderly on hemodialysis.
        Kidney Int. 2008; 73: 1289-1295
        • McAdams-DeMarco M.A.
        • Tan J.
        • Salter M.L.
        • et al.
        Frailty and cognitive function in incident hemodialysis patients.
        Clin J Am Soc Nephrol. 2015; 10: 2181-2189
        • National Kidney Foundation
        KDOQI clinical practice guidelines and clinical practice recommendations for vascular access 2006.
        Am J Kidney Dis. 2006; 48: S176-S322
        • Lok C.E.
        Fistula first initiative: advantages and pitfalls.
        Clin J Am Soc Nephrol. 2007; 2: 1043-1053
        • Allon M.
        • Robbin M.L.
        Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions.
        Kidney Int. 2002; 62: 1109-1124
        • Lee T.
        • Qian J.
        • Thamer M.
        • Allon M.
        Tradeoffs in vascular access selection in elderly patients initiating hemodialysis with a catheter.
        Am J Kidney Dis. 2018; 72: 509-518
        • Lee T.
        • Barker J.
        • Allon M.
        Tunneled catheters in hemodialysis patients: reasons and subsequent outcomes.
        Am J Kidney Dis. 2005; 46: 501-508
        • Nassar G.M.
        • Ayus J.C.
        Infectious complications of the hemodialysis access.
        Kidney Int. 2001; 60: 1-13
        • Allon M.
        • Daugirdas J.
        • Depner T.A.
        • Greene T.
        • Ornt D.
        • Schwab S.J.
        Effect of change in vascular access on patient mortality in hemodialysis patients.
        Am J Kidney Dis. 2006; 47: 469-477
        • Raithatha A.
        • McKane W.
        • Kendray D.
        • Evans C.
        Catheter access for hemodialysis defines higher mortality in late-presenting dialysis patients.
        Ren Fail. 2010; 32: 1183-1188
        • Viecelli A.K.
        • Howell M.
        • Tong A.
        • et al.
        Identifying critically important vascular access outcomes for trials in haemodialysis: an international survey with patients, caregivers and health professionals.
        Nephrol Dial Transplant. 2020; 35: 657-668
        • Hod T.
        • DeSilva R.N.
        • Patibandla B.K.
        • Vin Y.
        • Brown R.S.
        • Goldfarb-Rumyantzev A.S.
        Factors predicting failure of AV “fistula first” policy in the elderly.
        Hemodial Int. 2014; 18: 507-515
        • Drew D.A.
        • Lok C.E.
        • Cohen J.T.
        • Wagner M.
        • Tangri N.
        • Weiner D.E.
        Vascular access choice in incident hemodialysis patients: a decision analysis.
        J Am Soc Nephrol. 2015; 26: 183-191
        • Liu J.
        • Huang Z.
        • Gilbertson D.T.
        • Foley R.N.
        • Collins A.J.
        An improved comorbidity index for outcome analyses among dialysis patients.
        Kidney Int. 2009; 77: 141-151
        • Heinzl H.
        • Kaider A.
        Gaining more flexibility in Cox proportional hazards regression models with cubic spline functions.
        Comput Methods Programs Biomed. 1997; 54: 201-208
        • Desquilbet L.
        • Mariotti F.
        Dose-response analyses using restricted cubic spline functions in public health research.
        Stat Med. 2010; 29: 1037-1057
        • Latouche A.
        • Allignol A.
        • Beyersmann J.
        • Labopin M.
        • Fine J.P.
        A competing risks analysis should report results on all cause-specific hazards and cumulative incidence functions.
        J Clin Epidemiol. 2013; 66: 648-653
        • Muñoz A.
        • Abraham A.G.
        • Matheson M.
        • Wada N.
        Non-proportionality of hazards in the competing risks framework.
        in: Lee Mei-Ling Ting Gail Mitchell Pfeiffer Ruth Satten Glen Cai Tianxi Gandy Axel Risk Assessment and Evaluation of Predictions. Springer, New York, NY.2013: 3-22
        • Cole S.R.
        • Hernán M.A.
        Adjusted survival curves with inverse probability weights.
        Comput Methods Programs Biomed. 2004; 75: 45-49
        • Dignam J.J.
        • Kocherginsky M.N.
        Choice and interpretation of statistical tests used when competing risks are present.
        J Clin Oncol. 2008; 26: 4027-4034
        • Harrell F.E.
        Regression Modeling Strategies, With Applications to Linear Models, Logistic Regression, and Survival Analysis.
        Springer, New York, NY2001
        • Lilly M.P.
        • Lynch J.R.
        • Wish J.B.
        • et al.
        Prevalence of arteriovenous fistulas in incident hemodialysis patients: correlation with patient factors that may be associated with maturation failure.
        Am J Kidney Dis. 2012; 59: 541-549
        • Harford R.
        • Clark M.J.
        • Norris K.C.
        • Yan G.
        Relationship between age and timely placement of vascular access in incident patients on hemodialysis.
        Nephrol Nurs J. 2014; 41: 507-518
        • Swindlehurst N.
        • Swindlehurst A.
        • Lumgair H.
        • et al.
        Vascular access for hemodialysis in the elderly.
        J Vasc Surg. 2011; 53: 1039-1043
        • Weale A.R.
        • Bevis P.
        • Neary W.D.
        • et al.
        Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly.
        J Vasc Surg. 2008; 47: 144-150
        • Lok C.E.
        • Oliver M.J.
        • Su J.
        • Bhola C.
        • Hannigan N.
        • Jassal S.V.
        Arteriovenous fistula outcomes in the era of the elderly dialysis population.
        Kidney Int. 2005; 67: 2462-2469
        • Hall R.K.
        • Myers E.R.
        • Rosas S.E.
        • O’Hare A.M.
        • Colón-Emeric C.S.
        Choice of hemodialysis access in older adults: a cost-effectiveness analysis.
        Clin J Am Soc Nephrol. 2017; 12: 947-954
        • Lomonte C.
        • Basile C.
        • Mitra S.
        • et al.
        Should a fistula first policy be revisited in elderly haemodialysis patients?.
        Nephrol Dial Transplant. 2018; 34: 1636-1643
        • Misskey J.
        • Faulds J.
        • Sidhu R.
        • Baxter K.
        • Gagnon J.
        • Hsiang Y.
        An age-based comparison of fistula location, patency, and maturation for elderly renal failure patients.
        J Vasc Surg. 2018; 67: 1491-1500
        • Austin P.C.
        • Lee D.S.
        • Fine J.P.
        Introduction to the analysis of survival data in the presence of competing risks.
        Circulation. 2016; 133: 601-609
        • Thamer M.
        • Lee T.C.
        • Wasse H.
        • et al.
        Medicare costs associated with arteriovenous fistulas among US hemodialysis patients.
        Am J Kidney Dis. 2018; 72: 10-18
        • Lee T.
        • Qian J.
        • Zhang Y.
        • Thamer M.
        • Allon M.
        • et al.
        Long-term outcomes of arteriovenous fistulas with unassisted versus assisted maturation: a retrospective national hemodialysis cohort study.
        J Am Soc Nephrol. 2019; 30: 2209-2218
        • Lee T.
        • Qian J.
        • Thamer M.
        • Allon M.
        Gender disparities in vascular access surgical outcomes in elderly hemodialysis patients.
        Am J Nephrol. 2019; 49: 11-19

      Linked Article

      • The New Age of Vascular Access: Choosing the Right Access for the Right Reason in Older Hemodialysis Patients
        American Journal of Kidney DiseasesVol. 76Issue 4
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          According to the 2018 US Renal Data System (USRDS) report, 88% of the 125,000 incident patients with end-stage kidney disease (ESKD) in the United States select hemodialysis as their kidney replacement modality of choice.1 Among these patients, 80% use a central venous catheter (CVC) at hemodialysis initiation.1 Most patients who initiate hemodialysis with a CVC will subsequently undergo placement of a permanent vascular access: either an arteriovenous fistula (AVF) or an arteriovenous graft (AVG).
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