Mortality Outcomes Associated with Vascular Access Types in Hemodialysis for ESRD: A Systematic Review and Meta-Analysis

Mortality Outcomes Associated with Vascular Access Types in Hemodialysis for ESRD: A Systematic Review and Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mortality Outcomes Associated with Vascular Access Types in Hemodialysis for ESRD: A Systematic Review and Meta-Analysis Peng Miao, Zhengli Tan, Chenliang Yao, Zhiwen Cai, Zhengya Yu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7165622/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Dec, 2025 Read the published version in BMC Nephrology → Version 1 posted 14 You are reading this latest preprint version Abstract Background Hemodialysis is a common renal replacement therapy for patients with end-stage renal disease (ESRD). The common types of vascular access mainly include arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). However, the association between different access types and all-cause mortality remains controversial. Accordingly, this study aims to systematically assess the effect of different vascular access on mortality among hemodialysis patients with ESRD, thereby providing evidence-based recommendations for optimal vascular access strategies in clinical settings. Methods The systematic searches in PubMed, Embase, Cochrane Library and Web of Science were employed to determine the cohort study or randomized controlled trials comparing the effects of AVF, AVG, or CVC on mortality in patients undergoing hemodialysis. A total of 33 studies were included. Results Meta-analysis results showed the following: 1) All-cause mortality: Compared to AVF, CVCs significantly increased all-cause mortality. AVGs also increased all-cause mortality. 2) Cardiovascular events mortality: Compared to AVF, CVCs and AVGs showed a trend toward higher cardiovascular mortality, but the differences were not statistically significant. 3) In-hospital mortality: Compared to patients without vascular access, AVF was associated with increased in-hospital mortality. 4) Infection-related mortality: Compared to AVF, CVCs significantly increased infection-related mortality. Conclusion Compared with CVCs and AVGs, AVF remains the lowest mortality risk. Early planning and education regarding vascular access are essential to improve long-term outcomes in hemodialysis patients. end-stage renal disease hemodialysis vascular access mortality meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction End-stage renal disease (ESRD) represents a state of irreversible kidney failure, in which the kidneys are no longer able to maintain fluid, electrolyte, and metabolic homeostasis. The global prevalence of kidney failure continues to rise [ 1 ]. In 2015, kidney failure accounted for 1.2 million deaths [ 2 ]. Over 700,000 people in the United States were receiving treatment for kidney disease in 2016, and this number is expected to increase by 29–68% by 2030 [ 3 ]. On the basis of the 2018 U.S. Renal Data System (USRDS) annual report [ 1 ], more than 700,000 individuals in the U.S. Globally, the treated population with kidney failure is projected to grow from 2.6 million in 2010 to 5.4 million by 2030 [ 4 ]. Hemodialysis remains the most widely used modality of renal replacement therapy (RRT) and plays a vital role in enhancing quality of life and prolonging the survival of ESRD patients. In 2010, there were more than 2.6 million patients worldwide, with the majority undergoing hemodialysis, who received kidney replacement therapy (KRT) [ 1 , 4 , 5 ]. In the United States, over 60% of patients with kidney failure receive long-term hemodialysis, involving approximately 500,000 individuals [ 1 ]. Despite the long-standing use of hemodialysis since the advent of arteriovenous shunting in the 1960s, establishing and maintaining functional vascular access—the cornerstone of hemodialysis—remains a significant clinical challenge. Vascular access is a critical determinant of outcomes in hemodialysis patients. There are three main types of common vascular access: arteriovenous fistula (AVF), arteriovenous graft (AVG) and central venous catheter (CVC) [ 6 ]. Numerous studies have shown that AVFs are associated with the lowest complication and mortality rates, making them the preferred option for long-term access [ 7 , 8 ]. However, AVF creation and maintenance can be particularly challenging in elderly patients because of vascular calcification and decreased vessel quality, which increase the risk of AVF failure and early thrombosis [ 9 ]. Nevertheless, age alone should not be a contraindication for AVF use; the majority of patients need hemodialysis through functional vascular access, with AVF being the optimal standard [ 10 ]. Comorbid conditions also influence vascular access outcomes. For example, in patients with substantial comorbidity burdens such as cardiovascular disease or diabetes, AVGs may be associated with higher mortality risks than AVFs are [ 11 ]. Therefore, individualized vascular access planning that considers patient age, comorbidities, vascular anatomy, and life expectancy is essential to optimize clinical outcomes in ESRD patients. In summary, the choice of vascular access has a profound effect on survival outcomes in patients with ESRD. Although AVFs are generally preferred, the use of AVGs or CVCs may be necessary in elderly or medically complex patients, where the risks and benefits must be carefully balanced. Currently, high-quality systematic reviews that comprehensively summarize the available evidence on the relationship between vascular access type and mortality in ESRD patients are lacking. Therefore, the present study was designed to perform a systematic review and meta-analysis of the effects of different vascular access types on mortality among ESRD patients treated with hemodialysis, thereby providing evidence-based guidance for clinical decision-making. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were followed in the conduct of this systematic review [ 12 ], and the procedure has been documented in the International Prospective Register of Systematic Reviews (PROSPERO). Literature retrieval A thorough literature search was performed in PUBMED, EMBASE, the Cochrane Library, and Web of Science for papers published from the beginning of the databases to May 19, 2025, which investigated the associations between vascular access type and mortality in hemodialysis patients. The search strategy included both Medical Subject Headings (MeSH) and free-text terms related to "vascular access" and "hemodialysis." Keywords used in the search included “Vascular Access Device,” “Vascular Access Ports,” “Vascular Access Port,” “Renal Dialyzes,” “Hemodialysis,” and “Hemodialyzes.” In addition, we manually examined the bibliography of relevant systematic reviews to discover further qualifying studies. The complete search strategy is provided in Appendix 1. Inclusion and exclusion criteria The criteria for inclusion and exclusion were established according to the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework [ 13 ]. The inclusion criteria were as follows: 1) Patients who were undergoing hemodialysis and aged over 18 years. 2) The intervention group received one type of vascular access (fistula, graft, or catheter), and the control group received either another type of vascular access (fistula, graft, or catheter) or no vascular access intervention. 3) At least one of the following outcomes was assessed in the study: all-cause mortality, cardiovascular mortality, or infection-related mortality. 4) Study designs included randomized controlled trials (RCTs) or cohort studies. The exclusion criteria were as follows: 1) Patients who did not undergo hemodialysis or were under 18 years of age. 2) Studies in which the intervention was not related to vascular access. 3) Studies that did not report mortality-related outcomes. 4) Literature types, including previews, meta-analyses, animal studies, case reports, guidelines, letters, retracted articles, or conference abstracts. Literature selection and data extraction According to the predefined inclusion and exclusion criteria, two reviewers independently conducted the study selection process. First, all potentially relevant studies were imported into EndNote 21 to remove duplicates. Then, irrelevant studies were excluded by simply reading the article's title and abstract. Finally, full-text articles were assessed for eligibility. Any differences were resolved via discussion with a third researcher. Two reviewers independently extracted the appropriate data for each included study with a standardized data extraction form. The following information was collected: (1) basic study information (first author, year of publication, country); (2) study design (RCT or cohort study); (3) patient characteristics (sample size, age, sex, duration of dialysis); (4) details of vascular access types in the intervention and control groups (fistula, graft, or catheter); and (5) outcomes of interest (all-cause mortality, cardiovascular mortality, infection-related mortality). Any differences in data extraction will be accommodated via discussion with a third researcher. Risk of Bias Assessment The Newcastle‒Ottawa Scale (NOS) [ 14 ] is a widely recognized tool for quality assessment in case‒control and cohort studies and is known for its simplicity and ease of use. The scale uses a star system to assign a maximum of 9 stars, with higher scores indicating higher study quality. Unlike the Cochrane tool designed for randomized trials, the NOS assesses observational studies across three primary domains: selection, comparability, and exposure or outcome. A single star may be assigned to each item in a domain, except for Comparability, which can be awarded up to two stars. Statistical analysis Meta-analyses were performed via Stata version 15.0. Effect estimates are expressed as odds ratios (ORs) or hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). Pooled odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated via either a fixed-effects or a random-effects model, depending on heterogeneity. To evaluate heterogeneity among studies, the I² statistic was employed. An I² value of 0% indicates no observed heterogeneity; I² ≤ 50% indicates low heterogeneity, and I² >50% indicates substantial heterogeneity [ 15 ]. A fixed-effects model was used when heterogeneity was low (P > 0.1, I² ≤ 50%); otherwise (P ≤ 0.1, I² >50%), a random-effects model was used. Publication bias was assessed visually by funnel plot symmetry and statistically by Egger’s test [ 16 ]. A sensitivity analysis was conducted to assess the robustness of the aggregated results. A two-sided P value < 0.05 was considered statistically significant. Result Search results Four electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) were systematically searched to identify relevant studies, and initially identified 12,235 records. A total of 10,734 records were identified after duplicates were removed. Based on titles and abstracts, 10,635 records were excluded for not fulfilling the inclusion criteria. Remaining 99 articles, excluding 66 noncompliant papers by reading the full text included leads without a control group (n = 7), patients not on hemodialysis (n = 7), and not relevant to the study results (n = 52). After full-text review, 33 studies were deemed eligible and included in the meta-analysis. The study selection process is illustrated in Figure 1. Study characteristics Table 1 provides a summary of the characteristics of the included studies. A total of 33 cohort studies were included, involving 1,077,545 participants with an average age of 65.53 years. These studies were conducted across multiple countries: 11 in the United States, 4 in Japan, 4 in China, 2 in Turkey, and 1 each in Argentina, Brazil, Canada, Denmark, the Dominican Republic, India, Iran, Korea, Mexico, the Netherlands, Portugal, and Spain. All studies evaluated the association between different types of vascular access — fistula, graft, or catheter — and patient mortality outcomes. Specifically: 11 studies compared graft vs. fistula with respect to all-cause mortality. 18 studies compared catheter vs. fistula for all-cause mortality. 6 studies examined in-hospital mortality, among which 2 focused on catheter access and 4 on fistula. The impact of vascular access on cardiovascular and infection-related mortality was examined in four studies: 2 of them compared graft vs. fistula; the other 2 compared catheter vs. fistula. Quality assessment The methodological quality of the included cohort studies was evaluated using the NOS. The NOS assesses quality based on three domains: selection (0–4 points), comparability (0–2 points), and outcome (0–3 points), with a maximum score of 9. Among the 33 studies, 20 studies scored 9 points, 1 scored 8 points, and 11 studies scored 6. Overall, most studies were of moderate to high quality. Detailed quality assessment results are shown in Table 2. Meta-analysis All-cause mortality A total of 29 studies examined the impact of vascular access type on all-cause mortality in dialysis patients. Among these, 11 studies compared grafts to fistulas, whereas 18 studies compared catheters to fistulas. The meta-analysis results demonstrated that, compared with Fistula, both Catheters (OR = 2.48, 95% CI: 1.37–4.48, p < 0.0001; HR = 1.72, 95% CI: 1.57–1.89, p < 0.0001; Figure 2a and 2b) and Grafts (HR = 1.26, 95% CI: 1.21–1.32, p < 0.0001; Figure 2c) were associated with significantly increased all-cause mortality in dialysis patients. Notably, catheters were associated with a greater risk of mortality than grafts were. Therefore, in terms of all-cause mortality risk, Fistula had the lowest risk, followed by Graft, with Catheters having the highest risk. Assessment of publication bias revealed no significant bias in studies comparing graft versus fistula (p = 0.894) or catheter versus fistula (p = 0.476). Sensitivity analyses confirmed the robustness of the findings for both comparisons. The detailed information is provided in Appendix 2. In-hospital mortality Five studies assessed the impact of vascular access on all-cause mortality. Among them, two studies compared catheters with the absence of vascular access, whereas four studies compared fistulas with no vascular access. The meta-analysis revealed no statistically significant difference in in-hospital mortality between patients with catheters and those without vascular access (HR = 1.37, 95% CI: 1.00–1.88, p = 0.053; Figure 3). However, fistula use was significantly associated with increased in-hospital mortality (HR = 1.47, 95% CI: 1.21–1.77, p < 0.0001; Figure 3). Cardiovascular event mortality Two studies evaluated the association between vascular access type and mortality due to cardiovascular events. Both the graft and the catheter were compared to the fistula in these studies. The meta-analysis demonstrated that neither graft (HR = 1.24, 95% CI: 0.93–1.65, p = 0.145, Figure 4) nor catheter (HR = 1.64, 95% CI: 0.63–4.27, p = 0.308, Figure 4) showed a statistically significant difference in cardiovascular event mortality compared with Fistula. Infection mortality Two studies investigated the impact of vascular access type on infection-related mortality. Both studies compared the graft to the fistula and the catheter to the fistula. The meta-analysis results indicated that, compared with fistulas, catheters were linked to an increased risk of mortality due to infections (HR = 1.64, 95% CI: 0.63–4.27, p = 0.009; Figure 5), whereas no significant difference was observed between grafts and fistulas (HR = 1.13, 95% CI: 0.55–2.34, p = 0.735; Figure 5). Discussion This comprehensive analysis included 33 studies that focused on the effects of different vascular access types on mortality in patients with ESRD undergoing hemodialysis. The findings demonstrated a significant survival advantage associated with fistulas compared with grafts and catheters. Specifically, patients with fistulas had significantly lower all-cause mortality rates. In contrast, catheters were associated with the highest risk of mortality, particularly for both all-cause and infection-related deaths. The differences in mortality risk among vascular access types may be attributed to several underlying mechanisms. Fistulas, which are composed of native vessels, offer more stable hemodynamics and are less prone to thrombosis and catheter-related infections because of their physiological structure [ 17 ]. In contrast, grafts, which use synthetic materials, are associated with increased risks of thrombosis and infection due to mechanical irritation and potential immune responses [ 18 ]. Catheters are particularly vulnerable to bacterial colonization and bloodstream infections, as they are directly exposed to the external environment, making them among the primary risk factors for infection-related morbidity and mortality in dialysis patients [ 19 ]. Moreover, catheter use has been linked to heightened systemic inflammation, which may contribute to the progression of atherosclerosis and other cardiovascular complications [ 20 ]. This finding aligns with current clinical practice guidelines, which recommend AVFs as the preferred vascular access for hemodialysis [ 21 ]. Compared with AVGs or CVCs, AVFs are associated with fewer complications, greater access patency, and lower mortality risks [ 22 – 24 ]. Initiatives such as the 1997 National Kidney Foundation–Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) and the 2003 Fistula First Breakthrough Initiative have significantly increased AVF utilization rates in clinical practice [ 25 ]. Although AVGs serve as an alternative to AVFs, their survival advantage is somewhat inferior. Neointimal hyperplasia at the site of graft–vein anastomosis, resulting from vascular smooth muscle cell proliferation and migration, may partially account for this finding [ 26 – 29 ]. For individuals with end-stage renal disease on long-term hemodialysis, research has demonstrated that the surgical creation of AVFs or AVGs is generally preferable to that of CVCs [ 30 ]. However, both AVFs and AVGs are susceptible to thrombosis and eventual failure. CVCs, often used for temporary or emergency access, significantly increase the incidence of catheter-related infections, contributing to increased mortality—an association that was further confirmed in our study. Subgroup analyses in this study revealed no significant differences in cardiovascular mortality among different vascular access types, suggesting that the impact of access type on cardiovascular death may be relatively limited. In contrast, infection-related mortality was significantly associated with vascular access type, particularly with CVCs, which carry a markedly higher risk of infection than other access types do. These findings underscore the importance of infection prevention and catheter care in clinical practice. One of the strengths of this study lies in its comprehensive synthesis of the most up-to-date evidence, encompassing the effects of various vascular access types on multiple mortality outcomes. The study ensured the robustness of its findings through rigorous inclusion criteria and multiple sensitivity analyses. Furthermore, the classification of mortality into all-cause, infection-related, and cardiovascular-related categories provides more specific and clinically relevant guidance for practice. Nonetheless, this study has certain limitations. Most of the included studies were observational in nature, making it difficult to fully eliminate potential confounding factors. There was also heterogeneity across studies regarding definitions of vascular access and outcome measures. Additionally, the relatively short follow-up duration in some studies may have limited the analysis of long-term outcomes. Future research should focus on well-designed, multicenter prospective studies with standardized definitions of vascular access and outcome measures to further clarify the underlying mechanisms and support individualized treatment strategies. Conclusion This systematic review and meta-analysis demonstrated that different types of vascular access significantly impact mortality outcomes in patients with ESRD undergoing hemodialysis. AVFs, as first-line access options, are associated with a marked reduction in all-cause mortality and offer superior long-term survival benefits and safety compared with AVGs and CVCs. In contrast, CVCs are linked to a significantly increased risk of mortality, primarily due to infection and related complications, highlighting the need to avoid their long-term use whenever possible. These findings underscore the importance of optimizing vascular access selection and support current clinical strategies that prioritize the establishment of AVFs. They also call attention to the critical need for infection prevention and catheter management when CVCs are used. Prospective studies of higher methodological quality are necessary to further explore how different vascular access types are mechanistically associated with different mortality risks, thereby providing a more robust foundation for individualized treatment strategies in dialysis patients. Abbreviations ESRD End-stage renal disease AVF Arteriovenous fistula AVG Arteriovenous graft CVC Central venous catheter USRDS U.S. Renal Data System KRT Renal replacement therapy NOS Newcastle‒Ottawa Scale OR odds ratio CI Confidence interval HR hazard ratio KDOQI Kidney Disease Outcomes Quality Initiative. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing Interests There is no conflict of interest in relation to this study. Funding This review had no supported grant. Author Contribution Conception and design: PMAnalysis and interpretation: PM, YPFData collection: PM, ZLT, CLY, ZWCWriting the article: PMCritical revision of the article: ZLT, YPF, ZYYFinal approval of the article: PM, YPF, ZYZStatistical analysis: PM, CLY, ZWCOverall responsibility: PM Acknowledgements Not applicable. Data Availability Study protocol: Available at https://www.crd.york.ac.uk/PROSPERO/. 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Supplementary Files Table1.docx Table2.docx PRISMAchecklist.docx allcausemortality.docx Appendix12.docx Cite Share Download PDF Status: Published Journal Publication published 19 Dec, 2025 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 09 Oct, 2025 Reviews received at journal 07 Oct, 2025 Reviews received at journal 29 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviews received at journal 17 Sep, 2025 Reviewers agreed at journal 17 Sep, 2025 Reviews received at journal 11 Aug, 2025 Reviewers agreed at journal 11 Aug, 2025 Reviewers agreed at journal 10 Aug, 2025 Reviewers invited by journal 06 Aug, 2025 Editor assigned by journal 01 Aug, 2025 Submission checks completed at journal 31 Jul, 2025 First submitted to journal 31 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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University","correspondingAuthor":false,"prefix":"","firstName":"Zhengli","middleName":"","lastName":"Tan","suffix":""},{"id":498342695,"identity":"32dce548-7ccf-4f0e-aa05-c8b654b63692","order_by":2,"name":"Chenliang Yao","email":"","orcid":"","institution":"Beijing Tongren Hospital, Capital Meidcal University","correspondingAuthor":false,"prefix":"","firstName":"Chenliang","middleName":"","lastName":"Yao","suffix":""},{"id":498342696,"identity":"e9a186b6-61e7-4030-a351-5a06954bac7e","order_by":3,"name":"Zhiwen Cai","email":"","orcid":"","institution":"Beijing Tongren Hospital, Capital Meidcal University","correspondingAuthor":false,"prefix":"","firstName":"Zhiwen","middleName":"","lastName":"Cai","suffix":""},{"id":498342697,"identity":"061e8388-4948-4496-ac48-c9d195e6f543","order_by":4,"name":"Zhengya Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDACCWTOBwMbOVK0MDMwzihIMyZNCzPPh8OJBHXIz24+9vBrm13ihgP8xz7bGDAnMLAfProBnxbGOcfSjWXbkoFamJln5xiw5THwpKXdwKeFWSLHTFqyjRmshTnHgKeYQYLHDK8WNon8b0At9RAtFgYSiQ2EtPBI5LBJfmw7DNHCYGBAWIuERJqZNMO548YzDzAbM/YYJBizEfKL/IzkZ5I/yqpl+w4wPmb48ee/HD/74WN4tYAAMy8bg2OD/AOo7wgpBwHGH38Y7IlROApGwSgYBSMUAABAmkQ0+ZZeVwAAAABJRU5ErkJggg==","orcid":"","institution":"Beijing Tongren Hospital, Capital Meidcal University","correspondingAuthor":true,"prefix":"","firstName":"Zhengya","middleName":"","lastName":"Yu","suffix":""},{"id":498342701,"identity":"afc756d9-5ce4-4c8d-b42a-0d08811bcb1f","order_by":5,"name":"Yaping Feng","email":"","orcid":"","institution":"Beijing Tongren Hospital, Capital Meidcal University","correspondingAuthor":false,"prefix":"","firstName":"Yaping","middleName":"","lastName":"Feng","suffix":""}],"badges":[],"createdAt":"2025-07-19 16:23:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7165622/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7165622/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-025-04686-z","type":"published","date":"2025-12-19T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88783444,"identity":"94d6539d-5f53-4f95-bd41-1b60f44a1566","added_by":"auto","created_at":"2025-08-11 11:09:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":747029,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of literature search and selection.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/21ce67387a3485b8e19ded5c.png"},{"id":88782259,"identity":"d7c339f5-9f89-4811-b16e-9876e0213904","added_by":"auto","created_at":"2025-08-11 11:01:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":132904,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of all-cause mortality in dialysis patients.\u003c/p\u003e","description":"","filename":"Onlinefloatimage24.png","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/beba697b0a7231f295afacd1.png"},{"id":88783765,"identity":"30349144-cd33-4595-b7ed-cc1c07236975","added_by":"auto","created_at":"2025-08-11 11:17:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21129,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of in hospital mortality in dialysis patients.\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/4d3b6dbd4dbd3beb94dc61a4.png"},{"id":88784660,"identity":"74c880f8-fd3c-4479-b8af-4ec515c537f8","added_by":"auto","created_at":"2025-08-11 11:25:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":20626,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of cardiovascular events mortality in dialysis patients.\u003c/p\u003e","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/0c7040e5eab89730f11b3af5.png"},{"id":88783442,"identity":"827f6bae-b241-4186-b644-7fd08c5b2a2d","added_by":"auto","created_at":"2025-08-11 11:09:40","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":20493,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of infection mortality of dialysis patients.\u003c/p\u003e","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/008e61e5bb80eeb196976a56.png"},{"id":98813830,"identity":"1d3975a4-ce0e-4cf7-ad67-16a3c57b16e0","added_by":"auto","created_at":"2025-12-22 16:03:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":865752,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/3544255c-b75e-45c7-a00c-1e9fcda68faf.pdf"},{"id":88783441,"identity":"7c24a0d9-4b01-4899-98f2-22ec06057612","added_by":"auto","created_at":"2025-08-11 11:09:40","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":29990,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/c4a986ace41476a16c8ba497.docx"},{"id":88782262,"identity":"a742ab58-7672-49a9-8a5b-e4c20bc1265c","added_by":"auto","created_at":"2025-08-11 11:01:40","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22282,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/8201909a52fbcc4f886096ae.docx"},{"id":88782257,"identity":"c476d647-763c-4a08-bdce-e5007ab08dfe","added_by":"auto","created_at":"2025-08-11 11:01:40","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":28761,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMAchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/d3b1d32bac3c3b1f37e52e30.docx"},{"id":88782269,"identity":"4cf84812-7590-48d9-a4d3-7d121adb53ee","added_by":"auto","created_at":"2025-08-11 11:01:40","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":834574,"visible":true,"origin":"","legend":"","description":"","filename":"allcausemortality.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/d88a7d706fb8a0a2638d4903.docx"},{"id":88782260,"identity":"485c3a42-6bec-4dfe-9921-a64a272913a2","added_by":"auto","created_at":"2025-08-11 11:01:40","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":868168,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix12.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165622/v1/cc0ba5641e4900d8aff04606.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mortality Outcomes Associated with Vascular Access Types in Hemodialysis for ESRD: A Systematic Review and Meta-Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEnd-stage renal disease (ESRD) represents a state of irreversible kidney failure, in which the kidneys are no longer able to maintain fluid, electrolyte, and metabolic homeostasis. The global prevalence of kidney failure continues to rise [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2015, kidney failure accounted for 1.2\u0026nbsp;million deaths [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Over 700,000 people in the United States were receiving treatment for kidney disease in 2016, and this number is expected to increase by 29–68% by 2030 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. On the basis of the 2018 U.S. Renal Data System (USRDS) annual report [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], more than 700,000 individuals in the U.S. Globally, the treated population with kidney failure is projected to grow from 2.6\u0026nbsp;million in 2010 to 5.4\u0026nbsp;million by 2030 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHemodialysis remains the most widely used modality of renal replacement therapy (RRT) and plays a vital role in enhancing quality of life and prolonging the survival of ESRD patients. In 2010, there were more than 2.6\u0026nbsp;million patients worldwide, with the majority undergoing hemodialysis, who received kidney replacement therapy (KRT) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the United States, over 60% of patients with kidney failure receive long-term hemodialysis, involving approximately 500,000 individuals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the long-standing use of hemodialysis since the advent of arteriovenous shunting in the 1960s, establishing and maintaining functional vascular access—the cornerstone of hemodialysis—remains a significant clinical challenge. Vascular access is a critical determinant of outcomes in hemodialysis patients. There are three main types of common vascular access: arteriovenous fistula (AVF), arteriovenous graft (AVG) and central venous catheter (CVC) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Numerous studies have shown that AVFs are associated with the lowest complication and mortality rates, making them the preferred option for long-term access [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, AVF creation and maintenance can be particularly challenging in elderly patients because of vascular calcification and decreased vessel quality, which increase the risk of AVF failure and early thrombosis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Nevertheless, age alone should not be a contraindication for AVF use; the majority of patients need hemodialysis through functional vascular access, with AVF being the optimal standard [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eComorbid conditions also influence vascular access outcomes. For example, in patients with substantial comorbidity burdens such as cardiovascular disease or diabetes, AVGs may be associated with higher mortality risks than AVFs are [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, individualized vascular access planning that considers patient age, comorbidities, vascular anatomy, and life expectancy is essential to optimize clinical outcomes in ESRD patients.\u003c/p\u003e\u003cp\u003eIn summary, the choice of vascular access has a profound effect on survival outcomes in patients with ESRD. Although AVFs are generally preferred, the use of AVGs or CVCs may be necessary in elderly or medically complex patients, where the risks and benefits must be carefully balanced. Currently, high-quality systematic reviews that comprehensively summarize the available evidence on the relationship between vascular access type and mortality in ESRD patients are lacking. Therefore, the present study was designed to perform a systematic review and meta-analysis of the effects of different vascular access types on mortality among ESRD patients treated with hemodialysis, thereby providing evidence-based guidance for clinical decision-making.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were followed in the conduct of this systematic review [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and the procedure has been documented in the International Prospective Register of Systematic Reviews (PROSPERO).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLiterature retrieval\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA thorough literature search was performed in PUBMED, EMBASE, the Cochrane Library, and Web of Science for papers published from the beginning of the databases to May 19, 2025, which investigated the associations between vascular access type and mortality in hemodialysis patients. The search strategy included both Medical Subject Headings (MeSH) and free-text terms related to \"vascular access\" and \"hemodialysis.\" Keywords used in the search included “Vascular Access Device,” “Vascular Access Ports,” “Vascular Access Port,” “Renal Dialyzes,” “Hemodialysis,” and “Hemodialyzes.” In addition, we manually examined the bibliography of relevant systematic reviews to discover further qualifying studies. The complete search strategy is provided in Appendix 1.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion and exclusion criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe criteria for inclusion and exclusion were established according to the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe inclusion criteria were as follows: 1) Patients who were undergoing hemodialysis and aged over 18 years. 2) The intervention group received one type of vascular access (fistula, graft, or catheter), and the control group received either another type of vascular access (fistula, graft, or catheter) or no vascular access intervention. 3) At least one of the following outcomes was assessed in the study: all-cause mortality, cardiovascular mortality, or infection-related mortality. 4) Study designs included randomized controlled trials (RCTs) or cohort studies.\u003c/p\u003e\u003cp\u003eThe exclusion criteria were as follows: 1) Patients who did not undergo hemodialysis or were under 18 years of age. 2) Studies in which the intervention was not related to vascular access. 3) Studies that did not report mortality-related outcomes. 4) Literature types, including previews, meta-analyses, animal studies, case reports, guidelines, letters, retracted articles, or conference abstracts.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLiterature selection and data extraction\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccording to the predefined inclusion and exclusion criteria, two reviewers independently conducted the study selection process. First, all potentially relevant studies were imported into EndNote 21 to remove duplicates. Then, irrelevant studies were excluded by simply reading the article's title and abstract. Finally, full-text articles were assessed for eligibility. Any differences were resolved via discussion with a third researcher.\u003c/p\u003e\u003cp\u003eTwo reviewers independently extracted the appropriate data for each included study with a standardized data extraction form. The following information was collected: (1) basic study information (first author, year of publication, country); (2) study design (RCT or cohort study); (3) patient characteristics (sample size, age, sex, duration of dialysis); (4) details of vascular access types in the intervention and control groups (fistula, graft, or catheter); and (5) outcomes of interest (all-cause mortality, cardiovascular mortality, infection-related mortality).\u003c/p\u003e\u003cp\u003eAny differences in data extraction will be accommodated via discussion with a third researcher.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRisk of Bias Assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Newcastle‒Ottawa Scale (NOS) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] is a widely recognized tool for quality assessment in case‒control and cohort studies and is known for its simplicity and ease of use. The scale uses a star system to assign a maximum of 9 stars, with higher scores indicating higher study quality.\u003c/p\u003e\u003cp\u003eUnlike the Cochrane tool designed for randomized trials, the NOS assesses observational studies across three primary domains: selection, comparability, and exposure or outcome. A single star may be assigned to each item in a domain, except for Comparability, which can be awarded up to two stars.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eMeta-analyses were performed via Stata version 15.0. Effect estimates are expressed as odds ratios (ORs) or hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). Pooled odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated via either a fixed-effects or a random-effects model, depending on heterogeneity. To evaluate heterogeneity among studies, the I² statistic was employed. An I² value of 0% indicates no observed heterogeneity; I² ≤ 50% indicates low heterogeneity, and I² \u0026gt;50% indicates substantial heterogeneity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A fixed-effects model was used when heterogeneity was low (P \u0026gt; 0.1, I² ≤ 50%); otherwise (P ≤ 0.1, I² \u0026gt;50%), a random-effects model was used. Publication bias was assessed visually by funnel plot symmetry and statistically by Egger’s test [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A sensitivity analysis was conducted to assess the robustness of the aggregated results. A two-sided P value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003e\u003cstrong\u003eSearch results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) were systematically searched to identify relevant studies, and initially identified 12,235 records. A total of 10,734 records were identified after duplicates were removed. Based on titles and abstracts, 10,635 records were excluded for not fulfilling the inclusion criteria. Remaining 99 articles, excluding 66 noncompliant papers by reading the full text included leads without a control group (n = 7), patients not on hemodialysis (n = 7), and not relevant to the study results (n = 52). After full-text review, 33 studies were deemed eligible and included in the meta-analysis. The study selection process is illustrated in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 provides a summary of the characteristics of the included studies. A total of 33 cohort studies were included, involving 1,077,545 participants with an average age of 65.53 years. These studies were conducted across multiple countries: 11 in the United States, 4 in Japan, 4 in China, 2 in Turkey, and 1 each in Argentina, Brazil, Canada, Denmark, the Dominican Republic, India, Iran, Korea, Mexico, the Netherlands, Portugal, and Spain.\u003c/p\u003e\n\u003cp\u003eAll studies evaluated the association between different types of vascular access \u0026mdash; fistula, graft, or catheter \u0026mdash; and patient mortality outcomes. Specifically: 11 studies compared graft vs. fistula with respect to all-cause mortality. 18 studies compared catheter vs. fistula for all-cause mortality. 6 studies examined in-hospital mortality, among which 2 focused on catheter access and 4 on fistula. The impact of vascular access on cardiovascular and infection-related mortality was examined in four studies: 2 of them compared graft vs. fistula; the other 2 compared catheter vs. fistula.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe methodological quality of the included cohort studies was evaluated using the NOS. The NOS assesses quality based on three domains: selection (0\u0026ndash;4 points), comparability (0\u0026ndash;2 points), and outcome (0\u0026ndash;3 points), with a maximum score of 9. Among the 33 studies, 20 studies scored 9 points, 1 scored 8 points, and 11 studies scored 6. Overall, most studies were of moderate to high quality. Detailed quality assessment results are shown in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeta-analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAll-cause mortality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 29 studies examined the impact of vascular access type on all-cause mortality in dialysis patients. Among these, 11 studies compared grafts to fistulas, whereas 18 studies compared catheters to fistulas. The meta-analysis results demonstrated that, compared with Fistula, both Catheters (OR = 2.48, 95% CI: 1.37\u0026ndash;4.48, p \u0026lt; 0.0001; HR = 1.72, 95% CI: 1.57\u0026ndash;1.89, p \u0026lt; 0.0001; Figure 2a and 2b) and Grafts (HR = 1.26, 95% CI: 1.21\u0026ndash;1.32, p \u0026lt; 0.0001; Figure 2c) were associated with significantly increased all-cause mortality in dialysis patients. Notably, catheters were associated with a greater risk of mortality than grafts were. Therefore, in terms of all-cause mortality risk, Fistula had the lowest risk, followed by Graft, with Catheters having the highest risk.\u003c/p\u003e\n\u003cp\u003eAssessment of publication bias revealed no significant bias in studies comparing graft versus fistula (p = 0.894) or catheter versus fistula (p = 0.476). Sensitivity analyses confirmed the robustness of the findings for both comparisons. The detailed information is provided in Appendix 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn-hospital mortality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive studies assessed the impact of vascular access on all-cause mortality. Among them, two studies compared catheters with the absence of vascular access, whereas four studies compared fistulas with no vascular access. The meta-analysis revealed no statistically significant difference in in-hospital mortality between patients with catheters and those without vascular access (HR = 1.37, 95% CI: 1.00\u0026ndash;1.88, p = 0.053; Figure 3). However, fistula use was significantly associated with increased in-hospital mortality (HR = 1.47, 95% CI: 1.21\u0026ndash;1.77, p \u0026lt; 0.0001; Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCardiovascular event mortality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo studies evaluated the association between vascular access type and mortality due to cardiovascular events. Both the graft and the catheter were compared to the fistula in these studies. The meta-analysis demonstrated that neither graft (HR = 1.24, 95% CI: 0.93\u0026ndash;1.65, p = 0.145, Figure 4) nor catheter (HR = 1.64, 95% CI: 0.63\u0026ndash;4.27, p = 0.308, Figure 4) showed a statistically significant difference in cardiovascular event mortality compared with Fistula.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfection mortality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo studies investigated the impact of vascular access type on infection-related mortality. Both studies compared the graft to the fistula and the catheter to the fistula. The meta-analysis results indicated that, compared with fistulas, catheters were linked to an increased risk of mortality due to infections (HR = 1.64, 95% CI: 0.63\u0026ndash;4.27, p = 0.009; Figure 5), whereas no significant difference was observed between grafts and fistulas (HR = 1.13, 95% CI: 0.55\u0026ndash;2.34, p = 0.735; Figure 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis comprehensive analysis included 33 studies that focused on the effects of different vascular access types on mortality in patients with ESRD undergoing hemodialysis. The findings demonstrated a significant survival advantage associated with fistulas compared with grafts and catheters. Specifically, patients with fistulas had significantly lower all-cause mortality rates. In contrast, catheters were associated with the highest risk of mortality, particularly for both all-cause and infection-related deaths.\u003c/p\u003e\u003cp\u003eThe differences in mortality risk among vascular access types may be attributed to several underlying mechanisms. Fistulas, which are composed of native vessels, offer more stable hemodynamics and are less prone to thrombosis and catheter-related infections because of their physiological structure [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In contrast, grafts, which use synthetic materials, are associated with increased risks of thrombosis and infection due to mechanical irritation and potential immune responses [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Catheters are particularly vulnerable to bacterial colonization and bloodstream infections, as they are directly exposed to the external environment, making them among the primary risk factors for infection-related morbidity and mortality in dialysis patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, catheter use has been linked to heightened systemic inflammation, which may contribute to the progression of atherosclerosis and other cardiovascular complications [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis finding aligns with current clinical practice guidelines, which recommend AVFs as the preferred vascular access for hemodialysis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Compared with AVGs or CVCs, AVFs are associated with fewer complications, greater access patency, and lower mortality risks [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Initiatives such as the 1997 National Kidney Foundation\u0026ndash;Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) and the 2003 Fistula First Breakthrough Initiative have significantly increased AVF utilization rates in clinical practice [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough AVGs serve as an alternative to AVFs, their survival advantage is somewhat inferior. Neointimal hyperplasia at the site of graft\u0026ndash;vein anastomosis, resulting from vascular smooth muscle cell proliferation and migration, may partially account for this finding [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. For individuals with end-stage renal disease on long-term hemodialysis, research has demonstrated that the surgical creation of AVFs or AVGs is generally preferable to that of CVCs [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, both AVFs and AVGs are susceptible to thrombosis and eventual failure. CVCs, often used for temporary or emergency access, significantly increase the incidence of catheter-related infections, contributing to increased mortality\u0026mdash;an association that was further confirmed in our study. Subgroup analyses in this study revealed no significant differences in cardiovascular mortality among different vascular access types, suggesting that the impact of access type on cardiovascular death may be relatively limited. In contrast, infection-related mortality was significantly associated with vascular access type, particularly with CVCs, which carry a markedly higher risk of infection than other access types do. These findings underscore the importance of infection prevention and catheter care in clinical practice.\u003c/p\u003e\u003cp\u003eOne of the strengths of this study lies in its comprehensive synthesis of the most up-to-date evidence, encompassing the effects of various vascular access types on multiple mortality outcomes. The study ensured the robustness of its findings through rigorous inclusion criteria and multiple sensitivity analyses. Furthermore, the classification of mortality into all-cause, infection-related, and cardiovascular-related categories provides more specific and clinically relevant guidance for practice.\u003c/p\u003e\u003cp\u003eNonetheless, this study has certain limitations. Most of the included studies were observational in nature, making it difficult to fully eliminate potential confounding factors. There was also heterogeneity across studies regarding definitions of vascular access and outcome measures. Additionally, the relatively short follow-up duration in some studies may have limited the analysis of long-term outcomes. Future research should focus on well-designed, multicenter prospective studies with standardized definitions of vascular access and outcome measures to further clarify the underlying mechanisms and support individualized treatment strategies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review and meta-analysis demonstrated that different types of vascular access significantly impact mortality outcomes in patients with ESRD undergoing hemodialysis. AVFs, as first-line access options, are associated with a marked reduction in all-cause mortality and offer superior long-term survival benefits and safety compared with AVGs and CVCs. In contrast, CVCs are linked to a significantly increased risk of mortality, primarily due to infection and related complications, highlighting the need to avoid their long-term use whenever possible.\u003c/p\u003e\u003cp\u003eThese findings underscore the importance of optimizing vascular access selection and support current clinical strategies that prioritize the establishment of AVFs. They also call attention to the critical need for infection prevention and catheter management when CVCs are used. Prospective studies of higher methodological quality are necessary to further explore how different vascular access types are mechanistically associated with different mortality risks, thereby providing a more robust foundation for individualized treatment strategies in dialysis patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eESRD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnd-stage renal disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAVF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArteriovenous fistula\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAVG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArteriovenous graft\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCVC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentral venous catheter\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUSRDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eU.S. Renal Data System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKRT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRenal replacement therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNOS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNewcastle‒Ottawa Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eodds ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehazard ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKDOQI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKidney Disease Outcomes Quality Initiative.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eThere is no conflict of interest in relation to this study.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis review had no supported grant.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception and design: PMAnalysis and interpretation: PM, YPFData collection: PM, ZLT, CLY, ZWCWriting the article: PMCritical revision of the article: ZLT, YPF, ZYYFinal approval of the article: PM, YPF, ZYZStatistical analysis: PM, CLY, ZWCOverall responsibility: PM\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eStudy protocol: Available at https://www.crd.york.ac.uk/PROSPERO/. Statistical code and data set: Available on reasonable request from Dr. Zhengya Yu (E-mail: [email protected]).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Diabetes and Digestive and, Diseases K. (2018). https://doi.org/United States Renal Data System https://\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.usrds.org/2018/view/Default.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlobal regional. national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980\u0026ndash;2015: a systematic analysis for the Global Burden of Disease Study 2015. 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Cardiovasc Res. 2020;116(13):2142\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/cvr/cvz333\u003c/span\u003e\u003cspan address=\"10.1093/cvr/cvz333\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"end-stage renal disease, hemodialysis, vascular access, mortality, meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-7165622/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7165622/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHemodialysis is a common renal replacement therapy for patients with end-stage renal disease (ESRD). The common types of vascular access mainly include arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). However, the association between different access types and all-cause mortality remains controversial. Accordingly, this study aims to systematically assess the effect of different vascular access on mortality among hemodialysis patients with ESRD, thereby providing evidence-based recommendations for optimal vascular access strategies in clinical settings.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe systematic searches in PubMed, Embase, Cochrane Library and Web of Science were employed to determine the cohort study or randomized controlled trials comparing the effects of AVF, AVG, or CVC on mortality in patients undergoing hemodialysis. A total of 33 studies were included.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eMeta-analysis results showed the following: 1) All-cause mortality: Compared to AVF, CVCs significantly increased all-cause mortality. AVGs also increased all-cause mortality. 2) Cardiovascular events mortality: Compared to AVF, CVCs and AVGs showed a trend toward higher cardiovascular mortality, but the differences were not statistically significant. 3) In-hospital mortality: Compared to patients without vascular access, AVF was associated with increased in-hospital mortality. 4) Infection-related mortality: Compared to AVF, CVCs significantly increased infection-related mortality.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eCompared with CVCs and AVGs, AVF remains the lowest mortality risk. Early planning and education regarding vascular access are essential to improve long-term outcomes in hemodialysis patients.\u003c/p\u003e","manuscriptTitle":"Mortality Outcomes Associated with Vascular Access Types in Hemodialysis for ESRD: A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 11:01:35","doi":"10.21203/rs.3.rs-7165622/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-09T05:21:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-07T11:36:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-29T16:22:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25202129225626451667167904879555810385","date":"2025-09-27T13:10:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276530972730578914375891346296207179873","date":"2025-09-22T19:56:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T18:44:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139190059625285237493643034092812010938","date":"2025-09-17T15:27:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T11:51:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214955704721414973417464377727354055841","date":"2025-08-11T11:22:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313680563441314491404928118109093118367","date":"2025-08-10T16:32:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-06T16:11:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-01T10:13:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-31T16:53:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-07-31T16:50:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53e7d11a-9c62-4ded-bd2c-a7d70a05a1e1","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T15:59:18+00:00","versionOfRecord":{"articleIdentity":"rs-7165622","link":"https://doi.org/10.1186/s12882-025-04686-z","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2025-12-19 15:57:06","publishedOnDateReadable":"December 19th, 2025"},"versionCreatedAt":"2025-08-11 11:01:35","video":"","vorDoi":"10.1186/s12882-025-04686-z","vorDoiUrl":"https://doi.org/10.1186/s12882-025-04686-z","workflowStages":[]},"version":"v1","identity":"rs-7165622","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7165622","identity":"rs-7165622","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}