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Arteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival. We performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival. Of 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P <.05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P <.001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P =.03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P =.02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P =.36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P =.63). The absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals. [ABSTRACT FROM AUTHOR]

A patient's body mass index (BMI) can affect both perioperative and postoperative outcomes across all surgical specialties. Given that obesity and end-stage renal disease are growing in prevalence, we aimed to evaluate the association between BMI and outcomes of upper extremity arteriovenous (AV) access creation. A retrospective single-institution review was conducted for AV access creations from 2014 to 2018. Patient demographics, comorbidities, and AV access details were recorded. BMI groups were defined as normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-39.9 kg/m2), and morbidly obese (>40 kg/m2). Perioperative complications and long-term outcomes including access maturation (defined as access being used for hemodialysis or the surgeon's judgment that access was ready for use in patients not yet on hemodialysis), occlusion, and reintervention were evaluated. A total of 611 upper extremity AV access creations were performed on patients who were normal weight (29.6%), overweight (31.3%), obese (29.6%), and morbidly obese (9.5%). Access type included brachiocephalic (43.2%), brachiobasilic (25.5%), and radiocephalic (14.2%) fistulas and AV grafts (14.2%). Median age was 60.9 years, and 59.6% were male. Univariable analysis showed no difference between BMI groups for perioperative steal, hematoma, home discharge, or 30-day primary patency. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (44.5% ± 4.6% normal weight, 29% ± 3.8% overweight, 39.8% ± 4.3% obese, 34.7% ± 8% morbidly obese; P =.041). There was no difference in 2-year freedom from new access creation or survival. AV access maturity within 180 days differed between BMI groups (74.3% normal weight, 66% overweight, 65.7% obese, 46.6% morbidly obese; P <.001). On multivariable analysis, failure to mature within 180 days was associated with overweight (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.14-3.29; P =.002), obese (OR, 2.12; 95% CI, 1.19-3.47; P =.009), and morbidly obese (OR, 3.68; 95% CI, 1.85-7.3; P <.001) relative to normal weight BMI. AV access reintervention was associated with overweight (hazard ratio [HR], 1.83; 95% CI, 1.34-2.5), obese (HR, 1.56; 95% CI, 1.12-2.16), and morbidly obese (HR, 1.69; 95% CI, 1.1-2.58; P =.02) relative to normal weight BMI. BMI was not independently associated with long-term readmission or survival. Obesity is associated with higher rates of AV access failure to mature and reintervention. Surgeons performing access creation on obese patients must consider this for planning and setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms. [ABSTRACT FROM AUTHOR]

Despite improvements in treating human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), the risk of end-stage renal disease and need for long-term arteriovenous (AV) access for hemodialysis remain high in HIV-infected patients. Associations of HIV/AIDS with AV access creation complications have been conflicting. Our goal was to clarify short- and long-term outcomes of patients with HIV/AIDS undergoing AV access creation. The Vascular Quality Initiative registry was queried from 2011 to 2018 for all patients undergoing AV access creation. Documentation of HIV infection status with or without AIDS was recorded. Data were propensity score matched (4:1) between non-HIV-infected patients and HIV/AIDS patients. Subsequent multivariable analysis and Kaplan-Meier analysis were performed for short- and long-term outcomes. There were 25,711 upper extremity AV access creations identified: 25,186 without HIV infection (98%), 424 (1.6%) with HIV infection, and 101 (.4%) with AIDS. Mean age was 61.8 years, and 55.8% were male. Patients with HIV/AIDS were more often younger, male, nonwhite, nonobese, and current smokers; they were more often on Medicaid and more likely to have a history of intravenous drug use, and they were less often diabetic and less likely to have cardiac comorbidities (P <.05 for all). There was no significant difference in autogenous or prosthetic access used in these cohorts. Wound infection requiring incision and drainage or explantation within 90 days was low for all groups (0.6% vs 1.9 vs 0%; P =.11) of non-HIV-infected patients vs HIV-infected patients vs AIDS patients. Kaplan-Meier analysis showed no significant difference in 1-year freedom from primary patency loss (43.9% vs 46.3%; P =.6), 1-year freedom from reintervention (61% vs 60.7%,; P =.81), or 3-year survival (83% vs 83.8%; P =.57) for those with and without HIV/AIDS, respectively. Multivariable analysis demonstrated that patients with HIV/AIDS were not at significantly higher risk for access reintervention (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.76-1.24; P =.81), occlusion (HR, 1.06; 95% CI, 0.86-1.29; P =.6), or mortality (HR, 1.08; 95% CI, 0.83-1.43; P =.57). Patients with HIV/AIDS undergoing AV access creation have outcomes similar to those of patients without HIV infection, including long-term survival. Patients with HIV/AIDS had fewer traditional end-stage renal disease risk factors compared with non-HIV-infected patients. Our findings show that the contemporary approach for creation and management of AV access in patients with HIV/AIDS should be continued; however, further research is needed to identify risk factors in this population. [ABSTRACT FROM AUTHOR]