Transplant waitlisting attenuates the association between hemodialysis access type and mortality

  • Courtenay M. Holscher
  • Satinderjit S. Locham
  • Christine E. Haugen
  • Sunjae Bae
  • Dorry L. Segev
  • Mahmoud B. MalasEmail author
Original Article


Prior studies have shown that beginning hemodialysis (HD) with a hemodialysis catheter (HC) is associated with worse mortality than with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). We hypothesized that transplant waitlisting would modify the effect of HD access on mortality, given waitlist candidates’ more robust health status. Using the US Renal Data System, we studied patients with incident ESRD who initiated HD between 2010 and 2015 with an AVF, AVG, or HC. We used Cox regression including an interaction term for HD access and waitlist status. There were 587,607 patients that initiated HD, of whom 82,379 (14.0%) were waitlisted for transplantation. Only 26,264 (4.5%) were transplanted. Among patients not listed, those with an AVF had a 34% lower mortality compared to HC [adjusted hazard ratio (aHR) 0.66, 95% confidence interval (CI) 0.65–0.67] while those with an AVG had a 21% lower mortality compared to HC (aHR 0.79, 95% CI 0.77–0.81). Transplant waitlisting attenuated the association between hemodialysis access type and mortality (interaction p < 0.001 for both AVF and AVG vs. HC). Among patients on the waitlist, those with an AVF had a 12% lower mortality compared to HC (aHR 0.88, 95% CI 0.84–0.93), while those with an AVG had no difference in mortality (aHR 0.95, 95% CI 0.84–1.08). While all patients benefit from AVF or AVG over HC, the benefit was attenuated in waitlisted patients. Efforts to improve health status and access to healthcare for non-waitlisted ESRD patients might decrease HD-associated mortality and improve rates of AVF and AVG placement.


Hemodialysis access End-stage renal disease Kidney transplantation Transplant waitlisting 



This work was supported by Grants number F32DK109662 and K24DK101828 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), F32AG053025 from the National Institute on Aging (NIA), and an American College of Surgeons Resident Research Scholarship. The analyses described here are the responsibility of the authors alone and do not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products or organizations imply endorsement by the US Government.

Compliance with ethical standards

Conflict of interest

The authors of this manuscript have no conflicts of interest to disclose.  

Ethical approval

This study was considered exempt non-human subject research by the Johns Hopkins Medicine Institutional Review Board.


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Copyright information

© Italian Society of Nephrology 2019

Authors and Affiliations

  1. 1.Johns Hopkins University School of MedicineBaltimoreUSA
  2. 2.University of California San DiegoSan DiegoUSA
  3. 3.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA

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