Patient Frailty and Functional Use of Hemodialysis Vascular Access: A Retrospective Study of the US Renal Data System


Rationale and Objective

Despite the high prevalence of frailty among dialysis patients, it is unknown whether frailty is associated with dialysis vascular access failure. This study examined the association between frailty and functional use of vascular access.

Study Design

Retrospective observational study.

Setting and Participants

Patients who initiated hemodialysis through a tunneled catheter in the United States Renal Data System database from 2012-2017 and who underwent subsequent creation of an arteriovenous fistula or graft.


The “Claims-Based Frailty Indicator” (CFI) was calculated using a validated claims-based disability status model anchored to a well-described frailty phenotype.


Time to functional use for fistulas and grafts defined as the time from initiation of hemodialysis to treatments using the index vascular access with two needles.

Analytic Approach

Fine and Gray competing risk models separately examining fistula and graft outcomes. Patient survival was modeled for the entire cohort using Cox proportional hazards regression.


A total of 41,471 patients met inclusion criteria, including 33,212 who underwent fistula and 8,259 who underwent graft placement. Higher quartiles of the CFI were associated with a greater rate of mortality. Patients in the highest CFI quartile had over two times the rate of mortality compared to patients in the lowest CFI quartile (HR 2.49, 95% CI 2.41, 2.58). The highest quartile of CFI was significantly associated, in multivariable analyses, with longer time to fistula functional use (HR 0.65, 95% CI 0.62, 0.69) and graft functional use (HR 0.88, 95% CI 0.79, 0.98).


Generalizability may be limited by the requirement of 12 months of Medicare claims availability prior to initiation of dialysis. No data on patient anatomic characteristics nor on surgeon characteristics. Limited patient-specific sociodemographic data.


Higher degrees of frailty are associated with longer times to vascular access functional use. Frailty may be useful for informing clinical decision-making regarding choice of vascular access.

The full study is available in AJKD.