Effect of kidney transplantation activity on arteriovenous fistula use in prevalent haemodialysis patients: A registry-based study

Background: Kidney transplantation (KT) is considered to be the best kidney replacement therapy (KRT) option for most end-stage kidney disease (ESKD) patients. Arteriovenous fistula (AVF) is considered to be the best vascular access (VA) for most haemodialysis (HD) patients. In this study, we investigated the effect of KT activity on AVF use in prevalent HD patients. The probability of receiving a kidney graft (KTx) over time, depending on the first VA used to start the HD program, was also evaluated. Methods: Data from the Catalan Registry of prevalent patients on KRT by either KT or HD were examined over a 20-year period (1997-2017). Results: The percentage of prevalent ESKD patients with a functioning KTx increased from 40.5% in 1997 to 57.0% in 2017 and, conversely, the percentage of AVF utilisation in HD patients decreased from 86.0% to 63.2% during the same period (for both comparisons, p < 0.001). This inverse relationship was also demonstrated in other countries and regions worldwide by performing a simple linear regression analysis (R-2 = 0.4974, p = 0.002). The probability of prevalent patients dialysed through an AVF in Catalonia was independently associated with the percentage of functioning KTx among KRT population, after adjusting by age, gender, primary kidney disease, time on KRT, cardiovascular disease and type of HD Unit. Incident patients starting HD through an AVF had a significantly higher probability of receiving a KTx over time in comparison to patients who initiated HD through a catheter (hazard ratio 1.68 [95% confidence interval: 1.41-2.00], p < 0.001). Conclusions In addition to some demographical and clinical characteristics of patients and type of HD Unit, KT activity can be a determining factor in AVF use in prevalent HD patients. Starting an HD programme through an AVF is independently associated with a greater probability of receiving a KTx as compared to starting HD through a catheter.