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Age and Frailty are Key Predictors of Mortality in Patients Undergoing Initial Dialysis Access Creation: A 12-Year Longitudinal Analysis
Justin Yu, Erin Biggs, Dan Fort, Hernan Bazan, W. Charles Sternbergh, Samuel Money
Ochsner Clinic Foundation, Jefferson, LA
Background: Frailty is a common condition among patients requiring dialysis access, yet its impact on mortality remains underexplored. We aimed to assess the association between frailty and age on overall mortality in a long-term longitudinal study of patients undergoing initial dialysis access creation.
Methods: We conducted a retrospective cohort study of 1,873 patients who underwent their first arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation between February 2012 and June 2024 at a single tertiary referral center. Frailty was quantified using the Hospital Frailty Risk Index, and patients were stratified into low/intermediate and high frailty groups. Kaplan-Meier (KM) survival curves were generated to assess 5-year survival, and survival differences were evaluated using log-rank tests. Cox proportional hazards models were employed to estimate the risk of mortality associated with frailty and age.
Results: The study cohort had a mean age of 60.9 years and 57% were male. The overall survival rates were 76.8% at 3 years and 65.6% at 5 years. Log rank test revealed significant differences in survival based on frailty and age. Patients with high frailty scores had a 62.4% 5-year survival rate, compared to 79.8% in those with lower scores (p<0.001). The hazard ratio (HR) for mortality in high frailty patients was 1.52 (95% CI: 1.20-1.94) compared to their low frailty counterparts. The differences stratified by frailty were not observed until 3 years (Fig 1a). Age was a stronger predictor of mortality than frailty, with 5-year survival rates of 78.0%, 61.8%, and 43.7%, for patients aged <60 years, 60-74 years, and ≥75 years, respectively (p<0.001). When stratified by age, the differences in mortality were observed as early as 6 months (Fig 1b). Compared to those under 60, the HR for mortality in the 60-74 age group was 1.89 (95% CI: 1.53-2.34) and 3.24 (95% CI: 2.53-4.15) in patients aged ≥75 years.
Conclusions: This 12-year longitudinal analysis demonstrates that both age and frailty are significant predictors of mortality in patients undergoing initial dialysis access creation. The Hospital Frailty Risk Index can be used to predict mortality in this patient population, and can be readily implemented to automatically calculate and assist clinical decisions in this high-risk population. While frailty does impact survival, age emerges as a stronger and more predictive determinant of survival.
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