Outcomes of Autogenous Fistulas and Prosthetic Grafts for Hemodialysis Access in Diabetic and Non-Diabetic Patients.

INTRODUCTION: This study evaluates the effect of diabetes on outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in a large population based cohort of patients. METHODS: A retrospective cohort study of all patients who initiated dialysis in the United States Renal Database System (2007-2014). 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 of 381622 patients comprised 303307 (79.5%) autogenous fistulas and 78315 (20.5%) prosthetic grafts placed in 231134 (60.6%) diabetic and 150488 (39.4%) non-diabetic patients. There was decrease in maturation for diabetics compared to non-diabetics who received autogenous fistulas (aHR: 0.86; 95%CI: 0.83-0.88, P<0.001) and prosthetic grafts (aHR: 0.88; 95%CI: 0.83-0.93, P<0.001). Comparing diabetics vs. non-diabetics, primary patency at 5 years was 19.4 vs 23.5% (p<0.001) for autogenous fistulas and 9.1 vs 11.2% (p<0.001) for prosthetic grafts. Primary assisted patency at 5 years was 35.2 vs. 38.7% (p<0.001) for autogenous fistulas and 17.2 vs. 19.2% (p=0.015) for prosthetic grafts. While, Secondary patency at 5 years was 44.8 vs. 48.6% (p<0.001) for autogenous fistulas and 34.1 vs. 36.8% (p=0.002) for prosthetic grafts. There was 5% decrease in primary patency (aHR: 0.95; 95%CI: 0.94-0.96; p<0.001) for diabetics compared to non-diabetics who received autogenous fistulas. There was no difference in primary assisted and secondary patency for autogenous fistulas as well as primary, primary assisted and secondary patency for prosthetic grafts comparing diabetic to non-diabetic patients. There was also no significant difference in severe prosthetic graft infection between the groups (aHR: 0.99; 95%CI: 0.92-1.08; P=0.90). There was a 19% increase in patient mortality for diabetic relative to non-diabetic autogenous fistula recipients (aHR: 1.19; 95%CI: 1.17-1.20; P<0.001) and 12% increase for prosthetic graft recipients (aHR: 1.12; 95%CI: 1.10-1.15; P<0.001). CONCLUSIONS: In this population-based cohort of hemodialysis patients, diabetes mellitus was associated with a decrease in patient survival, access maturation and primary fistula patency. In contrast there was no association between diabetes and prosthetic graft patency and severe prosthetic graft infection warranting excision.