Arteriovenous fistula thrombosis is associated with increased all-cause and cardiovascular mortality in haemodialysis patients from the AURORA trial

Sophie Girerd; Nicolas Girerd; Luc Frimat; Hallvard Holdaas; Alan G Jardine; Roland E Schmieder; Bengt Fellström; Nicla Settembre; Sergei Malikov; Patrick Rossignol; Faiez Zannad

doi:10.1093/ckj/sfz048

Arteriovenous fistula thrombosis is associated with increased all-cause and cardiovascular mortality in haemodialysis patients from the AURORA trial

Clin Kidney J. 2019 May 11;13(1):116-122. doi: 10.1093/ckj/sfz048. eCollection 2020 Feb.

Authors

Sophie Girerd^{1

2

3}, Nicolas Girerd^{2

3}, Luc Frimat^{1

3}, Hallvard Holdaas⁴, Alan G Jardine⁵, Roland E Schmieder⁶, Bengt Fellström⁷, Nicla Settembre⁸, Sergei Malikov⁸, Patrick Rossignol^{2

3}, Faiez Zannad^{2

3}

Affiliations

¹ Department of Nephrology, University Hospital, Nancy, France.
² INSERM, Centre d'Investigation Clinique Plurithématique, University Hospital, Lorraine University, Nancy, France.
³ F-CRIN INI-CRCT, Nancy, France.
⁴ Medical Department, Rikshospitalet, University of Oslo, Oslo, Norway.
⁵ Renal Research Group, British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
⁶ Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany.
⁷ Department of Nephrology, University Hospital, Uppsala, Sweden.
⁸ Department of Vascular Surgery, University Hospital, Nancy, France.

Abstract

Background: The impact of arteriovenous fistula (AVF) or graft (AVG) thrombosis on mortality has been sparsely studied. This study investigated the association between AVF/AVG thrombosis and all-cause and cardiovascular mortality.

Methods: The data from 2439 patients with AVF or AVG undergoing maintenance haemodialysis (HD) included in the A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events trial (AURORA) were analysed using a time-dependent Cox model. The incidence of vascular access (VA) thrombosis was a pre-specified secondary outcome.

Results: During follow-up, 278 AVF and 94 AVG thromboses were documented. VA was restored at 22 ± 64 days after thrombosis (27 patients had no restoration with subsequent permanent central catheter). In multivariable survival analysis adjusted for potential confounders, the occurrence of AVF/AVG thrombosis was associated with increased early and late all-cause mortality, with a more pronounced association with early all-cause mortality {hazard ratio [HR] < 90 days 2.70 [95% confidence interval (CI) 1.83-3.97], P < 0.001; HR > 90 days 1.47 [1.20-1.80], P < 0.001}. In addition, the occurrence of AVF thrombosis was significantly associated with higher all-cause mortality, whether VA was restored within 7 days [HR 1.34 (95% CI 1.02-1.75), P = 0.036] or later than 7 days [HR 1.81 (95% CI 1.29-2.53), P = 0.001].

Conclusions: AVF/AVG thrombosis should be considered as a major clinical event since it is strongly associated with increased mortality in patients on maintenance HD, especially in the first 90 days after the event and when access restoration occurs >7 days after thrombosis. Clinicians should pay particular attention to the timing of VA restoration and the management of these patients during this high-risk period. The potential benefit of targeting overall patient risk with more aggressive treatment after AVF/AVG restoration should be further explored.

Keywords: arteriovenous fistula; arteriovenous graft; cardiovascular mortality; chronic haemodialysis; survival; vascular access complication.