First-line arteriovenous access and risks of hospitalization and death in patients starting hemodialysis - a nationwide cohort study

Arteriovenous (AV) access choice has sparked controversy with recent evidence suggesting overestimation of benefits associated with AV fistula versus graft in certain populations. We assessed outcomes associated with first-line AV access type in patients who started hemodialysis with a catheter in France, overall and by subgroups of age, sex, and comorbidities. In this retrospective cohort study, we included incident patients who initiated hemodialysis with a catheter from 2010 through 2018, followed by the French REIN Registry. Our main exposure was the first-line (first-created) AV graft versus fistula, ascertained through the linkage with the French national health-administrative database. Outcomes were all-cause and cause-specific hospitalization, and all-cause mortality. We used joint frailty models to deal with recurrent hospitalizations and informative censoring by death, Cox proportional hazard (PH) models, and inverse probability weighting. From the 18,625 patients included (mean age was 68{+/-}15 years, 35% were women), 5% had a first-line AV graft. Patients with AV graft had an 11%-higher weighted hazard of all-cause hospitalization (95% CI 1.09 to 1.13), 16% higher weighted hazard of cardiovascular (95% CI 1.05 to 1.29) and infection-related (95% CI 1.01 to 1.33) hospitalization, 34% higher weighted hazard of vascular access-related hospitalization, and a 9%-higher weighted hazard of all-cause death (95% CI 0.97 to 1.23). Results were consistent for most subgroups, except that the highest hazard of hospitalization with AV graft was blunted in patients with comorbidities (i.e. diabetes, weighted HR of all-cause hospitalization 1.03, 95% CI 0.95-1.12).- To conclude, in patients starting hemodialysis with a catheter, first-line AV graft is associated with increased hazard of hospitalization vs. patients with AV fistula. This may, however, not be the case for patients with a poor vascular condition, i.e., those with diabetes, who have a similar hospitalization and mortality rates with either graft or fistula.