For end-stage renal disease patients who start hemodialysis (HD) with a tunneled dialysis catheter (TDC), placement of an arteriovenous fistula (AVF) or arteriovenous graft (AVG) within 3 months results in similar life expectancy.
The findings contrast with existing guidelines, which have favored AVF placement. Both modalities appear superior to keeping a TDC in place.
Using U.S. Renal Data System databases, investigators led by Theodore H. Yuo, MD, of the University of Pittsburgh Medical Center, identified 138,245 ESRD patients started with a TDC from 2005–2008. In the first 3 months of hemodialysis, 22.8% of patients had an AVF created and 7.6% had an AVG placed. The remaining 69.6% continued to use a TDC.
Compared with AVG placement (reference), AVF creation was associated with a similar survival risk, but continued use of TDC was associated with a significant 54% increased risk of mortality, according to results published online ahead of print in Journal of Vascular Surgery.
AVF was associated with 22% higher mortality than AVG among a subset of patients older than age 80 with albumin levels greater than 4.0 g/dL. Although a biologically plausible mechanism for this finding is not clear, the investigators noted, Kidney Disease Outcomes Quality Initiative guidelines suggest that increased serum albumin concentrations are associated with improved long-term survival, leading to a recommended goal albumin level greater than 4.0 g/dL.
“AVG placement is equivalent to AVF creation and is superior to leaving a TDC in place in terms of survival in patients who start HD through a TDC in this retrospective review of administrative data,” the authors concluded. “These results suggest the need for a randomized controlled trial comparing fistulas and grafts in the subpopulation of dialysis patients who start HD with a TDC, with the goal of identifying the ideal access for patients in whom the survival advantage of AVF over AVG is uncertain.”
The researchers acknowledged a few important limitations of the study, including lack of accounting for the quality and diameter of the vein conduit, an assumption that all AVFs and AVGs provided usable access, and inability to capture important outcomes such as infection.
- Yuo, TH; Chaer, RA; Dillavou, ED; Leers, SA, and Makaroun, MS. Journal of Vascular Surgery; doi: 10.1016/j.jvs.2015.07.076.