title: The Effect of Predialysis Fistula Attempt on Risk of All-Cause and Access-Related Death.
abstract: Whether the lower risk of mortality associated with arteriovenous fistula use in hemodialysis patients is due to the avoidance of catheters or if healthier patients are simply more likely to have fistulas placed is unknown. To provide clarification, we determined the proportion of access-related deaths in a retrospective cohort study of patients aged ≥18 years who initiated hemodialysis between 2004 and 2012 at five Canadian dialysis programs. A total of 3168 patients initiated dialysis at the participating centers; 2300 met our inclusion criteria. Two investigators independently adjudicated cause of death using explicit criteria and determined whether a death was access-related. We observed significantly lower mortality in individuals who underwent a predialysis fistula attempt than in those without a predialysis fistula attempt in patients aged <65 years (hazard ratio [HR], 0.49; 95% confidence interval [95% CI], 0.29 to 0.82) and in the first 2 years of follow-up in those aged ≥65 years (HR0-24 months, 0.60; 95% CI, 0.43 to 0.84; HR24+ months, 1.83; 95% CI, 1.25 to 2.67). Sudden deaths that occurred out of hospital accounted for most of the deaths, followed by deaths due to cardiovascular disease and infectious complications. We found only 2.3% of deaths to be access-related. In conclusion, predialysis fistula attempt may associate with a lower risk of mortality. However, the excess mortality observed in patients treated with catheters does not appear to be due to direct, access-related complications but is likely the result of residual confounding, unmeasured comorbidity, or treatment selection bias.
authors.affiliation: Cumming School of Medicine, rob.quinn@ahs.ca.|Department of Community Health Sciences, and.
authors.forename: Robert R
authors.initials: RR
authors.lastname: Quinn
authors.affiliation: Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Oliver
authors.affiliation: Cumming School of Medicine.
authors.forename: Daniel
authors.initials: D
authors.lastname: Devoe
authors.affiliation: Cumming School of Medicine.
authors.forename: Krishna
authors.initials: K
authors.lastname: Poinen
authors.affiliation: Cumming School of Medicine.
authors.forename: Rameez
authors.initials: R
authors.lastname: Kabani
authors.affiliation: Cumming School of Medicine.
authors.forename: Fareed
authors.initials: F
authors.lastname: Kamar
authors.affiliation: Cumming School of Medicine.
authors.forename: Priyanka
authors.initials: P
authors.lastname: Mysore
authors.affiliation: Cumming School of Medicine.
authors.forename: Adriane M
authors.initials: AM
authors.lastname: Lewin
authors.affiliation: Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, The University of Ottawa, Ottawa, Canada.
authors.forename: Swapnil
authors.initials: S
authors.lastname: Hiremath
authors.affiliation: Cumming School of Medicine.
authors.forename: Jennifer
authors.initials: J
authors.lastname: MacRae
authors.affiliation: Cumming School of Medicine.|Department of Community Health Sciences, and.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: James
authors.affiliation: Department of Medicine, University of Manitoba, Winnipeg, Canada.
authors.forename: Lisa
authors.initials: L
authors.lastname: Miller
authors.affiliation: Cumming School of Medicine.|Department of Community Health Sciences, and.
authors.forename: Brenda R
authors.initials: BR
authors.lastname: Hemmelgarn
authors.affiliation: London Health Sciences Centre, London, Canada.|Department of Medicine, Western University, London, Canada; and.
authors.forename: Louise M
authors.initials: LM
authors.lastname: Moist
authors.affiliation: London Health Sciences Centre, London, Canada.|Department of Medicine, Western University, London, Canada; and.|Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Amit X
authors.initials: AX
authors.lastname: Garg
authors.affiliation: Department of Family Medicine, University of Calgary, Calgary, Canada.
authors.forename: Tanvir T
authors.initials: TT
authors.lastname: Chowdhury
authors.affiliation: Cumming School of Medicine.|Department of Community Health Sciences, and.
authors.forename: Pietro
authors.initials: P
authors.lastname: Ravani
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000401:mortality*; D002423:Cause of Death; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012189:Retrospective Studies; D018570:Risk Assessment
keywords: arteriovenous fistula; hemodialysis; hemodialysis access