Vascular access type and access-related outcomes among maintenance hemodialysis patients during armed conflict in Sudan: a retrospective cohort study

Armed conflict can disrupt systems that reduce vascular access complications in maintenance hemodialysis. This study evaluated whether access configuration at conflict onset was associated with access instability and infection-related mortality during the Sudan armed conflict. We reviewed a cohort of 122 adults who were receiving maintenance hemodialysis in Khartoum, Sudan, at conflict onset and had confirmed longitudinal follow-up for up to 18 months. Baseline access was classified as arteriovenous fistula, tunneled cuffed catheter, or temporary non-tunneled catheter. The primary outcome was first vascular access instability, defined as bloodstream infection, septic shock, mechanical dysfunction, or permanent access loss. Infection-related mortality was examined within the subgroup of patients who died. Multivariable models adjusted for age, diabetes mellitus, and dialysis duration. At conflict onset, access was arteriovenous fistula in 65 patients (53.3%), tunneled cuffed catheter in 37 (30.3%), and temporary non-tunneled catheter in 20 (16.4%). Temporary non-tunneled catheter users were younger and had shorter dialysis duration (both p < 0.001). Composite vascular access instability occurred in 24.6%, 40.5%, and 90.0%, respectively, giving an absolute risk difference of + 65.4% for temporary non-tunneled catheters versus arteriovenous fistulas. After adjustment, instability was higher with tunneled cuffed catheters (HR 2.03, 95% CI 1.09–3.78) and temporary non-tunneled catheters (HR 4.12, 95% CI 2.18–7.78). Among 57 deaths, 20 (35.1%) were infection-related. After adjustment for age, diabetes mellitus, and dialysis duration, temporary non-tunneled catheter use was associated with higher odds that death was infection-related among decedents, with arteriovenous fistula use as the reference (adjusted OR 9.84, 95% CI 1.87–51.8; p = 0.007). In this single-center cohort restricted to patients with confirmed follow-up, vascular access type was associated with access instability and with the proportion of deaths attributed to infection during armed conflict. These observational findings should be interpreted cautiously in view of non-random loss to follow-up, residual confounding, and possible outcome misclassification. Not applicable. This was a retrospective observational cohort study and was not prospectively registered as a clinical trial.