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

Keiichi Sumida; Miklos Z. Molnar; Praveen K. Potukuchi; Fridtjof Thomas; Jun Ling Lu; Vanessa A. Ravel; Melissa Soohoo; Connie M. Rhee; Elani Streja; Kunihiro Yamagata; Kamyar Kalantar-Zadeh; Csaba P. Kovesdy

Disclosures

Nephrol Dial Transplant. 2017;32(8):1330-1337. 

In This Article

Abstract and Introduction

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.

Introduction

Each year, as many as 115 000 patients transition from advanced non-dialysis-dependent chronic kidney disease (NDD-CKD) to end-stage renal disease (ESRD) in the USA,[1] the majority of whom are treated with in-center hemodialysis and require a vascular access,[2] such as an arteriovenous fistula (AVF) or graft (AVG), or a tunneled central venous catheter. Existing guidelines have encouraged the timely creation of an arteriovenous access as the preferred vascular access type rather than a central venous catheter,[2,3] based on the evidence that using an arteriovenous access can provide greater blood flow rates[4] and is associated with lower infection risk, fewer hospitalizations, prolonged survival and improved quality of life compared with using a central venous catheter.[5–11] The creation of an arteriovenous access may also have systemic physiological benefits, such as decreased total peripheral resistance and both systolic and diastolic blood pressure (BP), and increased stroke volume, left ventricular ejection fraction and cardiac output.[12,13] Furthermore, a recent study has demonstrated that successful AVF creation prior to dialysis initiation may be associated with a slowing of estimated glomerular filtration rate (eGFR) decline,[14] possibly due to functional and structural changes of endothelium induced by the local shear wall stress downstream from the created access.[15,16] However, it remains unclear if the observed association was specific to arteriovenous access creation and its associated physiological benefits versus confounding factors observed in late-stage NDD-CKD that influence eGFR independent of vascular access maturation.

In this study, we hypothesized that patients with an AVF/AVG are more likely to experience deceleration of eGFR decline after creation of AVF/AVG versus those without AVF/AVG, and that patients with a mature AVF/AVG would benefit more from its physiological effects on kidney function than those with a non-mature AVF/AVG. To test these hypotheses, we investigated the association of AVF/AVG creation with change in eGFR slopes using a large nationally representative cohort of US veterans with advanced CKD transitioning to dialysis.

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