The Association Between Frailty and Hemodialysis Vascular Access Fistula and Graft Failure
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The Association Between Frailty and Hemodialysis Vascular Access Fistula and Graft Failure


End-stage kidney disease (ESKD) is a grave public health problem in the US affecting over 808,000 Americans in 2017. Options for treatment of ESKD include renal transplantation and peritoneal dialysis. However, the most common treatment for ESKD in the US is hemodialysis, with over 468,000 Americans being hemodialysis dependent in 2017. For hemodialysis-dependent patients, vascular access is required, for which there are two options that are considered permanent, typically created in the upper extremity: 1) fistula, created by surgically connecting a patient’s own vein to an artery, and 2) graft, using a prosthetic tube as a conduit between artery and vein. However, evidence to support the choice of fistula vs graft in an individual patient is lacking. Frailty is a measure of patient global functional status and overall health that could be used in the decision-making progress to determine the optimal vascular access type for an individual patient. The objective of this dissertation is to investigate the association of frailty with probability of short-term vascular access failure to assess the usefulness of incorporating measurement of frailty into the vascular access decision-making process.I performed a quantitative analysis of the United States Renal Data Systems Registry which includes all hemodialysis dependent patients in the US. I determined the presence of frailty for each patient using a validated claims-based frailty indicator. I then assessed the association of frailty with time to fistula and graft functional use (the process of becoming usable for hemodialysis) using multivariable models. The analysis demonstrated that patients with increasing claims-based frailty indicator values have increasing length of time to fistula functional use. There was no association of claims-based frailty indicator value with time to graft functional use. The association between frailty and longer fistula functional use times has significant implications for clinical decision-making and guideline creation. Given that this study suggests frailty could also be associated with longer time to fistula functional use, frailty could serve as a strong indicator that fistula is not an appropriate choice of vascular access for that patient. Further, since increasing degrees of frailty, as measured by the claims-based frailty indicator, are associated with the highest risk of longer time to fistula m functional use in this study, it may be appropriate to consider patients with the highest levels of frailty as candidates for permanent access through a tunneled catheter.

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