Hemodialysis Arteriovenous Vascular Access Creation After Kidney Transplant Failure

Abstract

Background: Little is known about vascular access in patients starting hemodialysis therapy after kidney transplant failure.

Study design: Retrospective cohort study.

Setting & participants: Adult patients (aged ≥18 years) who started hemodialysis therapy in Ontario, Canada, from January 1, 2001, through December 31, 2010, after kidney transplant failure.

Predictor: Patient clinical and demographic characteristics.

Outcomes: Proportion and timing of arteriovenous (AV) vascular access creation (fistula or graft) 12 months prior and up to 24 months after starting hemodialysis therapy.

Measurements: Event rates and outcome predictors.

Results: Our cohort included 683 patients with a mean age of 48 years and >50% with comorbidity index score < 3. In the 12 months predialysis and 24 months postdialysis, 16% and 47% of patients had an AV access created, respectively. In the postdialysis period, 13%, 26%, and 38% of patients had an AV access creation at 3, 6, and 12 months, respectively. History of coronary artery disease, diabetes mellitus, and peritoneal dialysis use prior to transplantation were associated with a lower likelihood of AV access creation.

Limitations: Residual selection bias from unmeasured variables beyond the data elements.

Conclusions: In Ontario, AV access creation, both before and after starting hemodialysis therapy, is low in patients with kidney transplant failure despite their being younger and healthier compared to the overall hemodialysis population. This highlights the need for a predialysis care pathway in the transplantation clinic and an active strategy to identify this patient cohort receiving hemodialysis to align modality and access choices.

Keywords: Fistula First; Renal failure; arteriovenous fistula (AVF); arteriovenous graft (AVG); catheter; chronic kidney disease (CKD); fistula creation; hemodialysis; modality change; predialysis care; renal replacement therapy (RRT); transplant failure; vascular access.