Association between Timing of Vascular Access Creation and Mortality in Patients Initiating Hemodialysis: A Nationwide Cohort Study in Japan

Murakami, Minoru
Fujii, Naohiko
Kanda, Eiichiro
Kikuchi, Kan
Wada, Atsushi
Hamano, Takayuki
Masakane, Ikuto

^aDepartment of Nephrology, Saku Central Hospital, Nagano, Japan
^bCommittee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
^cMedical and Research Center for Nephrology and Transplantation, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
^dMedical Science, Kawasaki Medical School, Okayama, Japan
^eDivision of Nephrology, Shimoochiai Clinic, Tokyo, Japan
^fDepartment of Nephrology, Kitasaito Hospital, Asahikawa, Japan
^gDepartment of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
^hDepartment of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
ⁱDepartment of Nephrology, Yabuki Hospital, Yamagata, Japan

^*Minoru Murakami, [email protected]

Received June 14, 2024; Accepted August 30, 2024; previously published online September 07, 2024

American Journal of Nephrology 55(6):p 647-656, December 2024. | DOI: 10.1159/000541356

Abstract

Introduction:

The optimal time for vascular access (VA) creation remains controversial.

Methods:

We conducted a cohort study using data from the Japanese Society for Dialysis Therapy Renal Data Registry. Adult patients who started receiving hemodialysis in 2007 and had a permanent VA created were included. The exposure of interest was the timing of VA creation, categorized into three groups: early VA creation (defined as creation at least 4 months before hemodialysis initiation), just prior VA creation (creation between 1 and 3 months before hemodialysis initiation), and late VA creation (creation within 1 month of or after hemodialysis initiation). Cox regression analyses were used to compare 1-year all-cause mortality, with late VA creation as the reference group. Owing to the violations of the proportional hazards assumptions, the follow-up period was divided into “early” (1-4 months follow-up) and “late” (5-12 months follow-up) periods.

Results:

Overall, 1,280 (15.4%) of 8,322 patients died. Both early creation and just prior creation were associated with lower all-cause mortality in the early period compared with late creation. In the late period, the hazard ratios (HRs) for all-cause mortality decreased with earlier VA creation (adjusted HRs [95% confidence intervals]: 0.49 [0.35-0.67] for the early creation group and 0.63 [0.51-0.79] for the just prior creation group).

Conclusion:

Our study suggests that VA creation at least 1 month before hemodialysis initiation is associated with lower all-cause mortality in the early period, with earlier VA creation resulting in further mortality reduction in the late period.