Association between heart failure and arteriovenous access patency in patients with end-stage renal disease on hemodialysis.

INTRODUCTION: Heart disease and chronic kidney disease are often comorbid conditions due to shared risk factors including diabetes and hypertension. However, the effect of congestive heart failure on arteriovenous fistula and graft patency rates is poorly understood. We hypothesize preexisting heart failure may diminish blood flow to the developing AV fistula and worsen patency.

METHODS: We conducted a single-institution retrospective review of 412 patients with ESRD who underwent hemodialysis access creation from 2015-2021. Patients were stratified based on presence of pre-existing CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (<50%) or diastolic dysfunction on preoperative echocardiography (ECHO). Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for CHF vs. non-CHF patients, patients with reduced vs. normal EF, and graft vs. fistula in patients with CHF.

RESULTS: 204 patients (50%) had pre-existing CHF with confirmatory ECHO. Patients with CHF were more likely to be male and have comorbidities including diabetes, COPD, hypertension, and history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (p=0.99), BMI (p=0.74), or type of hemodialysis access created (p=0.54) (). There was no statistically significant difference in primary patency, primary assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank p>0.05 for all three patency measures). When stratified by preoperative LVEF, patients with EF < 50% had lower primary (38% vs. 51% at 1 year), primary assisted (76% vs. 82% at 1 year), and secondary patency (86% vs. 93% at 1 year) than those with normal EF. Difference reached significance for secondary patency only (log-rank p = 0.029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary assisted (39% vs. 87% at 1 year) and secondary (62% vs. 95%) patency for AVG (p < 0.0001 for both).

CONCLUSIONS: In this seven-year experience of hemodialysis access creation, reduced ejection fraction is associated with lower secondary patency. Preoperative CHF (including HFrEF and HFpEF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but CHF patients who receive AVG have markedly worse patency than those who receive AVF. For ESRD patients with CHF, risks and benefits must be carefully weighed particularly for those with low ejection fraction or lack of suitable vein for fistula creation.