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Timely AVF creation in late-referral hemodialysis patients, a two-cohort study: Too late to plan, not too late to act.

Elettra Lomeo,R. Mangiacapra,F. D'ascenzo,R. Gambhir,Mitta Nivedita,G. Grandaliano,Domenico Valenti,Francesco Pesce

Published 2025 in Journal of Vascular Access

ABSTRACT

BACKGROUND Timely vascular access creation in end-stage kidney disease is critical for optimizing patient outcomes. While early nephrology referral (⩾90 days pre-dialysis) improves access patency and survival, late referral is associated with worse outcomes. Healthcare system structure and demographics may impact vascular access strategies. This study compared late-referral hemodialysis patients from two high-volume hospitals in different healthcare systems, focusing on vascular access and survival. METHODS This retrospective, two-center study included 463 late-referral hemodialysis patients (mean age 60.4 ± 15.8 years; 63.3% male) initiating dialysis with a tunneled CVC between January 2020 and May 2024 at King's College Hospital, London (n = 249) and Policlinico A. Gemelli, Rome (n = 214). PRIMARY OUTCOME all-cause mortality. SECONDARY OUTCOMES AVF creation, primary and secondary AVF patency, and CRBSI. RESULTS AVF recipients had significantly lower mortality than non-AVF patients (p = 0.002), and a lower bacteremia rate (p = 0.05) across both Italy and UK cohorts (p = 0.005 and p = 0.0005, respectively). Time to AVF creation was significantly associated with mortality (OR 1.003; 95% CI 1.000-1.006; p = 0.02). AVF creation was achieved in 42.1% (n = 195), with primary patency rate of 62.7% at 6 months. Ethnicity (p = 0.01) and age (p = 0.0004) influenced AVF type selection. Among non-AVF patients, 26% declined surgery despite eligibility, showing reduced survival (p = 0.03). CRBSIs occurred in 16% of patients, mostly Gram-positive (70.3%). Relapse rate was higher with CVC removal/replacement than guidewire exchange (19.4% vs 0%; p = 0.01). CONCLUSIONS Early AVF creation in late-referral hemodialysis patients improves survival and reduces CRBSI risk. Reducing CVC requirement, especially in AVF-eligible patients, is a key strategy to improve outcomes.

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