Arteriovenous fistulas are associated with superior outcomes in very elderly hemodialysis patients: a nationwide cohort study

BACKGROUND/AIMS: The optimal vascular access strategy for very elderly patients initiating hemodialysis (HD) remains unclear. Arteriovenous fistulas (AVFs) offer long-term benefits but may be limited due to vascular aging. This study evaluated vascular access outcomes in patients aged ≥ 80 years. METHODS: We conducted a retrospective cohort study using data from the Korean National Health Insurance Service between 2008 and 2019. Patients aged ≥ 80 years who initiated HD with a newly created AVF or arteriovenous graft (AVG) were included. Primary outcomes were primary, assisted primary, and secondary patency. The secondary outcome was all-cause mortality. Outcomes were compared using Kaplan-Meier analysis and multivariable Cox regression. RESULTS: Among 8,487 patients, 5,124 (60.4%) received AVFs (AVF group) and 3,363 (39.6%) received AVGs (AVG group). AVFs were associated with significantly lower rates of patency loss across all definitions. The adjusted hazard ratios (HRs) for AVG vs. AVF were 1.76 (95% confidence interval [CI], 1.67-1.86) for primary patency loss, 1.90 (95% CI, 1.77-2.03) for assisted primary, and 3.18 (95% CI, 2.81-3.61) for secondary patency loss. All-cause mortality was also higher in the AVG group (adjusted HR, 1.24; 95% CI, 1.17-1.30). CONCLUSION: In this large-scale study, AVF use was associated with superior patency and lower mortality compared with AVG in patients aged ≥ 80 years. These findings suggest that AVF remains a beneficial option for appropriately selected elderly patients and that age alone should not be a primary barrier to its creation.