International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS).

RATIONALE & OBJECTIVE

Optimizing vascular access (VA) use is crucial for long-term hemodialysis (HD) patient care. As VA application varies internationally, we examined international differences in arteriovenous fistula (AVF) patency, and time to becoming catheter-free for patients receiving a new AVF STUDY DESIGN: Prospective cohort study SETTING & PARTICIPANTS: 2191 AVFs newly created in 2040 HD patients from 2009-2015 at 466 randomly-selected facilities in the Dialysis Outcomes and Practice Patterns Study, from US, Japan, and EUR/ANZ (Belgium, France, Germany, Italy, Spain, Sweden, United Kingdom, Australia, New Zealand).

PREDICTORS

Demographics, comorbidities, dialysis vintage, BMI, AVF location, country/region.

OUTCOMES

Primary/cumulative AVF patency (from creation), primary/cumulative functional patency (from first use), catheter-dependence duration, mortality ANALYTICAL APPROACH: Outcomes estimated via Cox regression RESULTS: Across regions, mean patient age ranged from 61-66 years, 55%-66% male, median dialysis vintage 0.3-3.2 years, with 84%, 54%, and 32% of AVFs created in the forearm in Japan, EUR/ANZ, and US. Japan displayed superior primary and cumulative patencies due to higher successful AVF use whereas cumulative functional patency was similar across regions. AVF patency associations with age and other patient characteristics were weak or varied considerably between regions. Catheter-dependence following AVF creation was much longer in EUR/ANZ and US patients, with nearly 70% remaining catheter-dependent eight months post-AVF creation when AVFs were not successfully used. Not using an AV access within 6 months of AVF creation was related to 53% higher mortality in the subsequent 6 months.

LIMITATIONS

Residual confounding.

CONCLUSION

Our findings highlight the need to reevaluate practices for optimizing long-term access planning and achievable AVF outcomes, especially AVF maturation. New AVFs that are not successfully used are associated with long-term catheter exposure and elevated mortality risk. These findings highlight the importance of selecting the best access type for each patient and developing effective clinical pathways for when AVFs fail to mature successfully.