title: Association between vascular access creation and deceleration of estimated glomerular filtration rate decline in late-stage chronic kidney disease patients transitioning to end-stage renal disease.
abstract: BACKGROUND
  Prior studies have suggested that arteriovenous fistula (AVF) or graft (AVG) creation may be associated with slowing of estimated glomerular filtration rate (eGFR) decline. It is unclear if this is attributable to the physiological benefits of a mature access on systemic circulation versus confounding factors.
  
  
  METHODS
  We examined a nationwide cohort of 3026 US veterans with advanced chronic kidney disease (CKD) transitioning to dialysis between 2007 and 2011 who had a pre-dialysis AVF/AVG and had at least three outpatient eGFR measurements both before and after AVF/AVG creation. Slopes of eGFR were estimated using mixed-effects models adjusted for fixed and time-dependent confounders, and compared separately for the pre- and post-AVF/AVG period overall and in patients stratified by AVF/AVG maturation. In all, 3514 patients without AVF/AVG who started dialysis with a catheter served as comparators, using an arbitrary 6-month index date before dialysis initiation to assess change in eGFR slopes.
  
  
  RESULTS
  Of the 3026 patients with AVF/AVG (mean age 67 years, 98% male, 75% diabetic), 71% had a mature AVF/AVG at dialysis initiation. eGFR decline accelerated in the last 6 months prior to dialysis in patients with a catheter (median, from -6.0 to -16.3 mL/min/1.73 m2/year, P < 0.001), while a significant deceleration of eGFR decline was seen after vascular access creation in those with AVF/AVG (median, from -5.6 to -4.1 mL/min/1.73 m2/year, P < 0.001). Findings were independent of AVF/AVG maturation status and were robust in adjusted models.
  
  
  CONCLUSIONS
  The creation of pre-dialysis AVF/AVG appears to be associated with eGFR slope deceleration and, consequently, may delay the onset of dialysis initiation in advanced CKD patients.
authors.affiliation: Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.|Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.|Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
authors.forename: Keiichi
authors.initials: K
authors.lastname: Sumida
authors.affiliation: Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Miklos Z
authors.initials: MZ
authors.lastname: Molnar
authors.affiliation: Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Praveen K
authors.initials: PK
authors.lastname: Potukuchi
authors.affiliation: Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Fridtjof
authors.initials: F
authors.lastname: Thomas
authors.affiliation: Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Jun Ling
authors.initials: JL
authors.lastname: Lu
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA.
authors.forename: Vanessa A
authors.initials: VA
authors.lastname: Ravel
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Soohoo
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA.
authors.forename: Connie M
authors.initials: CM
authors.lastname: Rhee
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA.
authors.forename: Elani
authors.initials: E
authors.lastname: Streja
authors.affiliation: Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
authors.forename: Kunihiro
authors.initials: K
authors.lastname: Yamagata
authors.affiliation: Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA.
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
authors.affiliation: Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.|Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA.
authors.forename: Csaba P
authors.initials: CP
authors.lastname: Kovesdy
mesh_terms: D000368:Aged; D001164:Arteriovenous Fistula / Q000150:complications*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D003654:Deceleration; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000473:pathology*; D008297:Male; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000601:surgery*; D012189:Retrospective Studies; D062666:Vascular Access Devices / Q000009:adverse effects*
keywords: arteriovenous access; chronic kidney disease; eGFR decline; hemodialysis