Arteriovenous Fistula Versus Graft Access Strategy in Older Adults Receiving Hemodialysis: A Pilot Randomized Trial

Abstract

Background: It is unclear whether surgical placement of an arteriovenous (AV) fistula (AVF) confers substantial clinical benefits over an AV graft (AVG) in older adults with end-stage kidney disease (ESKD). We report vascular access outcomes of a pilot clinical trial.

Study design: Pilot randomized parallel-group open-label trial.

Setting & participants: Patients 65 years and older with ESKD and no prior AV access receiving maintenance hemodialysis through a tunneled central venous catheter referred for AV access placement by their treating nephrologist.

Intervention: Participants were randomly assigned in a 1:1 ratio to surgical placement of an AVG or AVF.

Outcomes: Index AV access primary failure, successful cannulation, adjuvant interventions and infections.

Results: Of 122 older adults receiving hemodialysis and no prior AV access surgery, 24% died before (n = 18) or were too sick for (n = 11) referral for a permanent AV access. Of 46 eligible patients, 36 (78%) consented and were randomly assigned to AVG (n = 18) and AVF (n = 18) placement, of whom 13 (72%) and 16 (89%) underwent index AV access surgical placement, respectively. At a median follow-up of 321.0 days, primary AV access failure was noted in 31% in each group. The proportion of patients with successful cannulation was 62% (8 of 13) in the AVG and 50% (8 of 16) in the AVF group; median times to successful cannulation were 75.0 and 113.5 days, respectively. Endovascular procedures were recorded in 38% and 44%, and surgical reinterventions, in 23% and 25%, respectively. AV access infection was seen in 3 (23%) and 2 (13%) patients, respectively.

Limitations: Small sample size precludes statistical inference.

Conclusions: Almost one-quarter of older adults with incident ESKD and a central venous catheter as primary access were not referred for AV access placement due to medical reasons. Based on these limited results, there is little reason to favor either an AVF or AVG in this population until results from a larger randomized clinical trial become available.

Funding: Government funding to an author (Dr Murea is supported by National Institutes of Health∖National Institute on Aging grant 1R03 AG060178-01).

Trial registration: NCT03545113.

Keywords: Arteriovenous graft; arteriovenous fistula; hemodialysis; older adults; randomized trial.

Graphical abstract

Figure 1

Flow diagram. Screening and randomization between September 1, 2018, and February 29, 2020. Abbreviations: AV, arteriovenous; AVF, arteriovenous fistula; AVG, arteriovenous graft; CVC, central venous catheter; ESKD, end-stage kidney disease; HD, hemodialysis; PD, peritoneal dialysis.

Figure 2

Cumulative incidence of primary access failure. Shown are Kaplan-Meier event curves for the outcome of primary access failure in the arteriovenous fistula (AVF)-first and arteriovenous graft (AVG)-first groups.

Figure 3

Cumulative incidence of successful access cannulation. Shown are Kaplan-Meier event curves for the outcome of successful access cannulation in the arteriovenous (AV) fistula (AVF)-first and arteriovenous graft (AVG)-first groups.