Predictors of nonfunctional arteriovenous access at hemodialysis initiation and timing of access creation: A registry-based study

Abstract

Determinants of nonfunctional arteriovenous (AV) access, including timing of AV access creation, have not been sufficiently described. We studied 29 945 patients who had predialysis AV access placement and were included in the French REIN registry from 2005 through 2013. AV access was considered nonfunctional when dialysis began with a catheter. We estimated crude and adjusted odds ratio (OR) with 95% confidence intervals (CI) of nonfunctional versus functional AV access associated with case-mix, facility characteristics, and timing of AV access creation. Analyses were stratified by dialysis start condition (planned or as an emergency) and comorbidity profile. Overall, 18% patients had nonfunctional AV access at hemodialysis initiation. In the group with planned dialysis start, female gender (OR 1.43, 95% CI 1.32-1.56), diabetes (OR 1.28, 95% CI 1.15-1.44), and a higher number of cardiovascular comorbidities (OR 1.27, 95% CI 1.09-1.49, and 1.31, 1.05-1.64, for 3 and >3 cardiovascular comorbidities versus none, respectively) were independent predictors of nonfunctional AV access. A higher percentage of AV access creation at the region level was associated with a lower rate of nonfunctional AV access (OR 0.98, 95% CI 0.98-0.99 per 1% increase). The odds of nonfunctional AV access decreased as time from creation to hemodialysis initiation increased up to 3 months in nondiabetic patients with fewer than 2 cardiovascular comorbidities and 6 months in patients with diabetes or 2 or more such comorbidities. In conclusion, both patient characteristics and clinical practices may play a role in successful AV access use at hemodialysis initiation. Adjusting the timing of AV access creation to patients' comorbidity profiles may improve functional AV access rates.

Fig 1. Cohort selection.

Abbreviations: AV, arteriovenous.

Fig 2. Prevalence and adjusted odds ratios of nonfunctional AV access at hemodialysis initiation according to timing of AV access creation and comorbidities in patients with a planned dialysis start.

N* = number of patients within time lags through the 20 imputed data sets. Analyses were adjusted for all variables in Table 1 plus year of hemodialysis initiation and the region’s annual percentage of patients with predialysis AV access. P-value of interaction between comorbidity profile and timing of AV access creation: 0.059. P-value of timing of AV access creation in both stratified models: <0.001. Abbreviations: AV, arteriovenous; ref, reference.