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Socioeconomic And Racial Influences On Hemodialysis Arteriovenous Access Outcomes: A Vascular Quality Initiative Study
Keivan Ranjbar, MD1, Jeongin Jang, BS
1, Rahul Rodrigues, BS
1, Gautam Bulusu, BS
1, Prashanth Palvannan, MD, MPH
1, Shivani Kumar, MD
1, Jeffery Siracuse, MD
2, Payam Salehi, MD, PhD
1.
1Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA, USA,
2Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA.
OBJECTIVES: Arteriovenous access is essential for long-term hemodialysis. The creation and maintenance of an arteriovenous fistula (AVF) or an arteriovenous graft (AVG) are critical for effective dialysis and minimizing complications. However, the influence of race and social determinants of health on presentation, management, and outcomes has not been well evaluated. This study uses the Vascular Quality Initiative (VQI) database to evaluate disparities in vascular access outcomes by race and community-level disadvantage.
METHODS: We analyzed patients undergoing AVF or AVG creation between 2016-2023 using the VQI database. The Area Deprivation Index (ADI), a validated measure of neighborhood socioeconomic disadvantage incorporating income, education, employment, and housing quality, was categorized into quartiles from least (Q1) to most disadvantaged (Q4). Patients without follow-up, complication data, or ADI status were excluded. Outcomes by race and ADI were compared using chi-square and t-tests. Multivariable logistic regression adjusted for demographic and clinical covariates.
RESULTS:A total of 77,544 patients were included (mean age 62.2 years, 43.4% female). White patients represented the largest racial group (51.5%, n=39,959), and 29.5% (n=22,850) were from the most disadvantaged ADI quartile. Maturation failure was higher in White vs Black patients (adjusted OR 1.43, 95% CI 1.21-1.70, p<0.001) and higher in Q4 vs Q1 (OR 1.58, 1.26-1.98, p<0.001). Immediate postoperative bleeding was less common in White vs Black patients (0.6% vs 0.9%; OR 0.58, 0.43-0.79, p<0.001) and less frequent in Q4 vs Q1 (0.5% vs 1.2%; OR 0.36, 0.25-0.53, p<0.001). At 9 months, access patency was lower in Black vs White patients (86.4% vs 88.2%, p=0.003) and varied by ADI (p<0.001), with Q1 achieving the highest patency (88.7%). Nine-month mortality was highest in White patients (28% vs 21% in Black, p<0.001 unadjusted); however, only Asian race remained independently protective after adjustment (OR 0.41, 0.35-0.47, p<0.001 vs Black). Patients in Q4 had significantly higher 9-month mortality compared to Q1 (adjusted OR 1.56, 1.46-1.67, p<0.001).
CONCLUSIONS: Significant disparities in hemodialysis access outcomes exist by race and socioeconomic status. Patients in disadvantaged areas experienced higher maturation failure and mortality. Black and American Indian/Alaskan Native patients had worse patency and greater AVG use. Structural and social factors strongly influence vascular access outcomes, underscoring the need for targeted interventions to improve equity in hemodialysis care.
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