Impact Of Active Smoking On Outcomes Of Arteriovenous Fistulas And Grafts For Hemodialysis Access
Isibor J. Arhuidese, MD1, Christina K. Tran, MD1, Angelyn Thayer, MD1, Mary E. Ottinger, MD1, Aurelia T. Calero, MD1, Mahmoud Malas, MD2, Murray Shames, MD1.
1University of South Florida, Tampa, FL, USA, 2UCSD, San Diego, CA, USA.
OBJECTIVES: This study evaluates the effect of active smoking on outcomes of arteriovenous fistulas (AVF) and graft (AVG) for hemodialysis access in a large population based cohort of patients.
METHODS: A retrospective cohort study of all patients with surgical dialysis access in the United States Renal Database System (2007-2015). Chi-square, student T-tests, Kaplan-Meier, log-rank tests, multivariable logistic and Cox regression analyses were employed to evaluate maturation, interventions, patency, infection and mortality.
RESULTS: The study population included 381622 patients with 303307 (79.5%) AVF’s and 78315 (20.5%) prosthetic grafts placed in 22515 (5.9%) active smokers and 359107 (94.1%) non-smokers. There was no significant difference in maturation for smokers compared to non-smokers who received AVF (aHR: 1.01; 95%CI: 0.98-1.03, P=0.57) or AVG (aHR: 0.99; 95%CI: 0.95-1.04, P=0.83). Comparing smokers vs. non-smokers, primary patency at 5 years was 18.8 vs 21.2% (p<0.001) for AVF and 10.2 vs 9.9% (p=0.026) for AVG. Primary assisted patency at 5 years was 34 vs. 36.8% (p<0.001) for AVF and 17.5 vs. 18% (p=0.25) for AVG. Secondary patency at 5 years was 43.5 vs. 46.5% (p<0.001) for AVF and 34.8 vs. 35.1% (p=0.70) for AVG. There was a decrease in primary (aHR: 0.97; 95%CI: 0.95-0.99; p=0.001), primary assisted (aHR: 0.97; 95%CI: 0.95-0.99; p=0.019) and secondary (aHR: 0.97; 95%CI: 0.95-0.99; p=0.007) patency for smokers compared to non-smokers who received and AVF. There was a decrease in primary patency (aHR: 0.96; 95%CI: 0.93-0.99; p=0.033) for smokers compared to non-smokers who received AVG. There was no difference in primary assisted patency, secondary patency or severe AVG infection between the groups. There was a 23% increase in patient mortality for smokers relative to non-smokers who received AVF (aHR: 1.23; 95%CI: 1.20-1.25; P<0.001) and 16% increase for AVG recipients (aHR: 1.16; 95%CI: 1.11-1.21; P<0.001).
CONCLUSIONS: In this population-based cohort of hemodialysis patients, smoking was associated with an decrease in patient survival and access patency. There was no association between smoking and AV access maturation or severe prosthetic graft infection. These outcomes support the recommendation for smoking cessation in these patients.
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