# Patterns and Outcomes of Permanent Vascular Access in End-Stage Kidney Disease: A Multicenter Experience

## TL;DR

This study examines the use and outcomes of different types of permanent vascular access in patients with end-stage kidney disease undergoing hemodialysis, finding that arteriovenous fistulas have the best performance and that anemia is a key factor in access failure.

## Contribution

The study provides new insights into vascular access patterns and outcomes in ESKD patients, identifying anemia as a critical modifiable risk factor for access failure.

## Key findings

- Arteriovenous fistulas (AVFs) showed the lowest failure rates compared to other vascular access types.
- Hemoglobin levels below target (<12 g/dL) were independently associated with higher odds of vascular access failure.
- Older age (≥65 years) was associated with lower odds of vascular access failure.

## Abstract

Background

End-stage kidney disease (ESKD) is a growing health problem worldwide, with hemodialysis serving as the main treatment when transplantation is not feasible. Permanent vascular access is essential for effective dialysis, yet its patterns and outcomes remain variable across patient populations.

Aim

This multicenter study aimed to describe the patterns of vascular access use and evaluate the outcomes of permanent vascular access in patients with ESKD undergoing hemodialysis.

Methods

A retrospective multicenter cross-sectional study (January-June 2024) was conducted at two tertiary hospitals in Al-Ahsa, Saudi Arabia, including adults on maintenance hemodialysis via arteriovenous fistula (AVF), arteriovenous graft (AVG), or permanent catheter. Demographic, clinical, laboratory, and access data were extracted. Pending accesses were excluded from inferential analyses. Group comparisons used standard non-parametric and categorical tests; independent predictors of failure were estimated using logistic regression with two-sided α=0.05 (p<0.01 interpreted as strong evidence).

Results

Among 378 patients, permanent catheter use predominated [standard 193 (51.1%), long-standing 70 (18.5%)], followed by AVFs 113 (29.9%) and AVGs 2 (0.5%). Overall, 324 (85.7%) accesses were patent, 29 (7.7%) failed, and 25 (6.6%) were pending. In those with known status (n=353), access type was significantly associated with outcome: AVF failures 6 (5.3%), standard catheter failures 23 (13.7%), and no failures among long-standing catheters or AVGs-though these groups were small. Failed cases exhibited below-target hemoglobin levels. In multivariable analysis, hemoglobin below target (<12 g/dL) was independently associated with higher odds of failure (OR 0.17 for below vs within/above target, 95% CI 0.04-0.76; p=0.020), whereas older age (≥65 years) was associated with lower failure odds (OR 0.39, 95% CI 0.16-0.97; p=0.043).

Conclusions

In this multicenter experience, AVF use aligned with the most favorable patency profile. Anemia emerged as the most actionable correlate of failure, underscoring the importance of hemoglobin optimization around access creation and maintenance. Early planning for AVF and targeted surveillance, especially with anemia correction, was associated with greater permanent access durability.