Association of hemodialysis vascular access type with dialysis adequacy and access-related outcomes in patients receiving maintenance hemodialysis

BackgroundVascular access type may be associated with the delivered hemodialysis dose and access-related morbidity; however, nonrandom access selection introduces confounding. We evaluated the associations of arteriovenous fistula (AVF), arteriovenous graft (AVG), and tunneled central venous catheter (CVC) use with dialysis adequacy and access-related outcomes.MethodsThis retrospective study included 285 adults whose index access was first successfully used between 2020 and 2023, with follow-up through 2024. Monthly single-pool Kt/V (spKt/V) measurements during the first 6 months were analyzed using mixed-effects models. Recurrent complications were reported as rates per 100 access-years. Cox regression and Kaplan–Meier methods were used to evaluate the first composite complication and permanent access failure, respectively. Models were adjusted for prespecified baseline factors, including a history of urgent-start dialysis, previous access attempts, vascular mapping, and residual kidney urea clearance; the interval from access creation or placement to first successful use was examined in sensitivity analyses.ResultsThe AVF, AVG, and CVC groups included 156, 67, and 62 patients, respectively, and contributed 1,632 adequacy measurements. Compared with CVC use, adjusted monthly spKt/V was higher with AVF use (β = 0.23, 95% confidence interval [CI] 0.17–0.29; P < 0.001) and AVG use (β = 0.11, 95% CI: 0.04–0.18; P = 0.002). Recurrent composite-complication rates were 8.84, 26.60, and 54.69 per 100 access-years, respectively (P < 0.001). AVF use was associated with a lower hazard of the first composite complication than CVC use (hazard ratio [HR] = 0.39, 95% CI: 0.23–0.66; P < 0.001), whereas the estimate for AVG was not statistically significant. Among accesses that had reached successful clinical use, 12-month observed access survival from first successful use was 94.0%, 84.7%, and 57.4% in the AVF, AVG, and CVC groups, respectively.ConclusionsAVF use was associated with higher dialysis adequacy and a lower burden of access-related complications than CVC use. Among accesses that had reached successful clinical use, AVFs showed longer observed access survival than AVGs and CVCs. Access selection should integrate clinical urgency, vascular anatomy, anticipated access use, comorbidity, residual kidney function, and patient priorities.