Background: Preemptive arteriovenous (AV) access creation before hemodialysis reduces catheter dependency and improves survival. However, its effectiveness in very old patients, such as octogenarians (aged 80-90 years) and nonagenarians (>90 years), remains unclear. We evaluated whether initiating hemodialysis with AV access provides survival benefits in these patients using the Korean National Health Insurance Service database. Methods: We retrospectively analyzed patients who started hemodialysis between 2012 and 2021, categorized by initial vascular access as AV fistula (AVFs), AV grafts (AVGs), or central venous catheters (CVCs). Patients with AV access at initiation were compared with those who started with CVCs and later underwent AV access creation. Subgroup analyses were performed by age, sex, and diabetes mellitus (DM). Results: Among 68,393 patients, 29,381 (43.0%) had initial AV and 39,012 (57.0%) had CVC-to-AV. Overall, the initial AV group was associated with better survival than the CVC-to-AV group (adjusted hazard ratio HR, 1.388; 95% confidence interval CI, 1.353- 1.424; p < 0.001). Among octogenarians, initial AVF and AVG were associated with better survival than CVC-to-AVF (HR, 1.297; 95% CI, 1.208-1.392; p < 0.001) and CVC-to-AVG (HR, 1.232; 95% CI, 1.122-1.354; p < 0.001), particularly in patients with DM. In nonagenarians, initial AVF showed no survival benefit (HR, 0.928; 95% CI, 0.673-1.279; p = 0.648), whereas initial AVG showed an association with improved survival (HR, 1.593; 95% CI, 1.064-2.386; p = 0.024). Conclusion: Initiating hemodialysis with AV access was associated with improved survival in older and very old patients. AV access creation can be reasonably considered in very old pre-dialysis patients.
Park et al. (Tue,) studied this question.