Abstract: SA-PO0437
Attributable Influence of Incident Vascular Access on Survival Benefits Associated with Predialysis Kidney Care
Session Information
- Dialysis: Vascular Access
November 08, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 803 Dialysis: Vascular Access
Authors
- Shukla, Ashutosh M., VA North Florida South Georgia Veterans Health System, Gainesville, Florida, United States
- Scheiffele, Grant D., University of Florida, Gainesville, Florida, United States
- Parmar, Cydney El Cid, VA North Florida South Georgia Veterans Health System, Gainesville, Florida, United States
- Huang, Wenxi Huang, University of Florida, Gainesville, Florida, United States
- Liu, Mei, University of Florida, Gainesville, Florida, United States
- Xu, Qi, University of Florida, Gainesville, Florida, United States
- Guo, Yi, University of Florida, Gainesville, Florida, United States
- Guo, Serena Jingchuan, University of Florida, Gainesville, Florida, United States
- Pramod, Sheena, University of Florida, Gainesville, Florida, United States
Background
Pre-dialysis renal care is associated with higher incident vascular access and longer survival on dialysis. Studies are conflicting but have shown a potential survival benefit with incident vascular access; however, conventional analyses fail to fully account for these competing influences.
Methods
Analyzing 2021 USRDS, we identified all adult ESKD patients with >6-month pre-dialysis Medicare initiating hemodialysis between 2010-2019. Using causal mediation analysis with a 16-variable Cox Proportional Hazard model, and pre-dialysis renal care as exposure, composite incident AVF or AVG as mediator(reference group:CVC-only), and 3-year post-ESKD survival as outcome, we examined the attributable influence of incident AVF/AVG on survival advantage conferred by pre-dialysis renal care. We conducted extensive sensitivity analysis modulating exposure duration and secondary analyses modulating mediator to maturing AVF/AVG.
Results
Of 427,340 eligible incident ESKD patients, 261,527(61%), 200,694(47%), and 122,655 140,269(28%) received any, >6-month, and >12-month pre-dialysis renal care, respectively. Incident AVF/AVG was used in 75,238(18%, AVF:62,075 & AVG:13,163), maturing AVF/AVG with CVC in 74,663(18%), and 276,652(64%) used CVC-only. Compared to those without, pre-dialysis renal care was associated with 12-fold(aOR:11.75, 95%CI:11.27-12.24) higher use of incident AVF/AVG, 3-fold(aOR:2.64, 95%CI:2.57-2.71) higher rates of maturing AVF/AVG, and 24% lower mortality (aHR:0.76, 95%CI:0.76-0.77) at 3 years. Compared to CVC-only, incident AVF/AVG was associated with 40% lower (aHR:0.60, 95%CI: 0.59-0.61) and maturing AVF/AVG was associated with 25% lower (aHR:0.75, 95%CI: 0.74-0.76) 3-year mortality. Mediation analyses showed that differential AVF/AVG use explained 37% and maturing AVF/AVG explained 17% of survival difference between those with and without pre-dialysis renal care (p<0.0001). Sensitivity analyses incorporating a longer pre-dialysis renal care slightly diminished but maintained significant attributable influence of AVF/AVG on survival.
Conclusion
By quantifying the attributable influence and through extensive sensitivity and secondary analyses, our findings highlight the importance of incident vascular access as a major determinant of post-ESKD survival.