Left ventricular ejection fraction: association with risk of mortality and the incidence of arteriovenous fistula dysfunction (medium-term results)

Background. Ejection fraction (EF) and chronic heart failure (HF) are often considered as criteria for the possibility of arteriovenous fistula (AVF) creation due to an increased risk of death, without sufficient evidence for this. There is, however, rare but compelling evidence that low EF increases the risk of AVF dysfunction. Objective. The objective of this study was to evaluate the association between EF at the time of AVF creation and the incidence of adverse cardiovascular events, all-cause mortality, as well as AVF dysfunction. Methods. This retrospective cohort study included 962 adult patients who had a first-time-created functioning AVF. Only patients with a more than three months and less than five years period after AVF creation were included. The mean follow-up period was 34±13 months. Four groups were identified based on EF and the presence of HF at the time of AVF creation: HF with reduced EF (rEF) <40%, with mid-range (mrEF) of 40-49%, or with preserved EF (pEF) ≥50% + HF, and a "no HF" group with EF≥50% and no HF. Results. In the univariate analysis, a reduced EF was associated with an increased risk of mortality, with the hazard ratios (HRs) of 2.706 [95% CI 1.330; 5.507], p=0.006 for mrEF and 8.250 [95% CI 2.621; 25.97], p<0.001 for rEF, compared to the "no HF" group (here and thereafter). However, after adjusting for age, sex, and Charlson Comorbidity Index (CCI), EF was not significantly associated with the risk of death. Only the CCI score remained a significant factor (HR=1.748 [95% CI 1.482; 2.063], p<0.001). A decreased EF was associated with the incidence of AVF dysfunction both in the univariate analysis and after adjustments. In the univariate analysis, the incidence rate ratios (IRRs) of 6.88 [95% CI 3.88; 12.1], p<0.001 for mrEF, and 19.9 [95%DI 8.64; 41.6], p<0.001 for rEF, were shown. After adjusting for age, sex, and CCI, the IRR for mrEF was 8.96 [95% CI 5.81; 13.7], p<0.001, and for rEF, it was 23.4 [95% CI 13.8; 38.6], p<0.001. Even in the presence of polycystic kidney disease and diabetes mellitus in the most comprehensive model, the association between EF and the incidence of AVF dysfunction remained statistically significant: the IRR was 8.61 [95%DI 5.61; 13.1], p<0.001 for mrEF, and 33.4 [95%DI 19.5; 56.2], p<0.001 for rEF. The findings were confirmed after adjusting for urgent HD initiation and in the competing risks survival analysis. Conclusions. In patients who are initiating treatment with maintenance hemodialysis, a decreased EF is associated to a greater extent with a higher risk of AVF dysfunction than with an increased risk of mortality. The burden of comorbidities, rather than a standalone assessment of EF, is one of the major risk factors determining patient survival.

артериовенозная фистула, гемодиализ, фракция выброса, хроническая сердечная недостаточность, нежелательные сердечно-сосудистые события, arteriovenous fistula, hemodialysis, ejection fraction, chronic heart failure, adverse cardiovascular events

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