Does Vascular Access Type Affect Access–Related Costs?

Successful treatment of ESKD with maintenance hemodialysis (HD) is inextricably dependent on reliable access to the bloodstream, typically three times a week. The vascular access, therefore, is the literal “lifeline” for the patient on HD. In numerous studies, including a meta-analysis of 62 cohort studies with 586,337 participants, patients dialyzing with an arteriovenous (AV) fistula have been observed to have less morbidity and mortality (1). Although AV fistulas are the preferred form of vascular access if they can become functional, they are limited by high rates of nonuse. Specifically, substantial proportions (20%–60%) of new AV fistulas are never useable for dialysis or require assistance to mature and be functional (1). In a comparative national study on elderly patients on HD, we found that AV grafts were almost twice as likely as AV fistulas to be successfully used for dialysis within 6 months (adjusted odds ratio, 1.86; 95% confidence interval, 1.73 to 1.99), that an intervention to achieve successful use for dialysis was required more frequently in patients with an AV fistula versus those with an AV graft (odds ratio, 2.66; 95% confidence interval, 2.26 to 3.12), and that patients receiving an AV fistula had a 2-month longer catheter dependence prior to successful use compared with patients with AV grafts ( P <0.001) (2).Taking these issues into consideration, Kosa et al. (3) conducted an innovative study comparing the costs of attaining and maintaining patency for AV fistulas compared with AV grafts among patients on HD. In addition to comparing undifferentiated costs over 1, 3, and 5 years, the authors analyzed AV access type and risk of failure to mature (FTM) on total costs. Given the higher rates of nonmaturation among AV fistulas, this analysis provides a new and perhaps more appropriate (or “fair”) basis in which to compare and analyze …