Characterization of Long-term Survival in Medicare Patients Undergoing Arteriovenous Hemodialysis Access

Patients undergoing arteriovenous (AV) access creation for hemodialysis often have significant comorbidities. Our goal was to quantify the long-term survival and associated risks factors for long-term mortality in these patients to aid in optimization of goals and expectations. The Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Vascular Quality Initiative Medicare linked data was used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. As the majority of HD patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality. There were 13,945 AV access patients analyzed including 10,872 (78%) AV fistulas and 3,073 (22%) AV grafts. The median age was 67 year and 56% of patients were male. Approximately one third had a prior AV access and 44.7% had prior tunneled dialysis catheters. Patients receiving an AV fistula, compared to AV grafts, were more often younger, male, white, obese, independently ambulatory, preoperatively living at home, and less often have a prior AV access and tunneled dialysis catheters (P<.05 for all). The 5-year mortality overall was 62.9% with 61.2% for AV fistulas and 68.8% for AV grafts (P<.001). On multivariable analysis for 5 year mortality, non-ambulatory status (HR 1.67, 95% CI 1.53 – 1.83, P<.001), lower extremity access (HR 1.67, 95% CI 1.35 – 2.05, P<.001), HIV/AIDS (HR 1.44, 95% CI 1.13 – 1.82, P<.001), White race (HR 1.43, 95% CI 1.35 – 1.51, P<.001), congestive heart failure (HR 1.33, 95% CI 1.26 – 1.41, P<.001), chronic obstructive pulmonary disease (HR 1.23, 95% CI 1.15 – 1.31, P<.001), and AV graft placement (HR 1.12, 95% CI 1.02 – 1.23, P = .016) were most associated with poor survival. Factors associated with improved survival were never smoking (HR .73, 95% CI .67 – .79, P<.001), prior/quit smoking (HR .78, 95% CI .72 – .84, P<.001), preoperative home living (HR .75, 95% CI .68 – .83, P<.001) and hypertension (HR .89, 95% CI .8 – .99, P=.03). Long-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. There are many modifiable risk factors that may improve survival in these patients and give an opportunity for transplantation.