Patient-related factors influencing the choice of haemodialysis access in Sweden

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Abstract
Background: Haemodialysis access patterns differ internationally. This can not only be explained by differences in patient cohorts. What is considered the right access for the right patient is debated and it is unclear which patient-related factors affect the choice of access. The aim of the study was to investigate how patient-specific factors as body size and comorbidities influenced the choice of haemodialysis access in a real-life setting. Methods: Retrospective cohort study including all patients receiving a haemodialysis access in Sweden between 2013 and 2022. Data from the Swedish Renal Registry (SNR) and the National Patient Register (NPR) was used. Data regarding age, sex, cause of kidney failure, previous kidney replacement therapy, height and weight (after dialysis), were collected from SNR. Data on comorbidities were extracted both from SNR and the NPR. AV-accesses were grouped into four categories depending on location of artery. Changes in arteriovenous access creation over time and patient-related factors affecting the choice of first access were analysed. Results: Of 10,170 patients, 9706 with 17,709 accesses were included. The creation of upper-arm fistulas ( p = 0.042) and arteriovenous grafts ( p = 0.007) increased. Small body size, female sex, diabetes mellitus, vintage, previous haemodialysis treatment (all p < 0.001), age ( p = 0.002) and peripheral arterial disease ( p = 0.031) led to more central venous catheters. Small body size, female sex, peripheral arterial disease, vintage, previous haemodialysis treatment (all p < 0.001) and diabetes mellitus ( p = 0.023) decreased the probability for selecting a forearm fistula. Upper-arm fistulas were preferred over arteriovenous grafts for those with small body size ( p < 0.001 for body surface area), female sex ( p = 0.003) and previous haemodialysis ( p < 0.001). Conclusions: The use of upper-arm fistulas and arteriovenous grafts is increasing, while forearm arteriovenous fistulas remain the primary access modality. Patient-related factors influencing the choice of access seemed to be related to vessel size and quality, rather than age and cardiovascular comorbidities.

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