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American Journal of Kidney Diseases

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

  • Joyce Z. Qian
    Correspondence
    Address for Correspondence: Joyce Z. Qian, PhD, Medical Technology and Practice Patterns Institute (MTPPI), 5272 River Rd, Ste 665, Bethesda, MD 20816.
    Affiliations
    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
    Affiliations
    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
    Affiliations
    Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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  • Bryan Lau
    Affiliations
    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.

      Exposure

      Age at dialysis initiation.

      Outcomes

      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.

      Results

      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.

      Limitations

      Reliance on administrative claims to ascertain AVF outcomes.

      Conclusions

      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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      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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