Timely AVF creation in late-referral hemodialysis patients, a two-cohort study: Too late to plan, not too late to act

Background: Timely vascular access creation in end-stage kidney disease is critical for optimizing patient outcomes. While early nephrology referral (>= 90 days pre-dialysis) improves access patency and survival, late referral is associated with worse outcomes. Healthcare system structure and demographics may impact vascular access strategies. This study compared late-referral hemodialysis patients from two high-volume hospitals in different healthcare systems, focusing on vascular access and survival.Methods: This retrospective, two-center study included 463 late-referral hemodialysis patients (mean age 60.4 +/- 15.8 years; 63.3% male) initiating dialysis with a tunneled CVC between January 2020 and May 2024 at King's College Hospital, London (n = 249) and Policlinico A. Gemelli, Rome (n = 214). Primary outcome: all-cause mortality. Secondary outcomes: AVF creation, primary and secondary AVF patency, and CRBSI.Results: AVF recipients had significantly lower mortality than non-AVF patients (p = 0.002), and a lower bacteremia rate (p = 0.05) across both Italy and UK cohorts (p = 0.005 and p = 0.0005, respectively). Time to AVF creation was significantly associated with mortality (OR 1.003; 95% CI 1.000-1.006; p = 0.02). AVF creation was achieved in 42.1% (n = 195), with primary patency rate of 62.7% at 6 months. Ethnicity (p = 0.01) and age (p = 0.0004) influenced AVF type selection. Among non-AVF patients, 26% declined surgery despite eligibility, showing reduced survival (p = 0.03). CRBSIs occurred in 16% of patients, mostly Gram-positive (70.3%). Relapse rate was higher with CVC removal/replacement than guidewire exchange (19.4% vs 0%; p = 0.01).Conclusions: Early AVF creation in late-referral hemodialysis patients improves survival and reduces CRBSI risk. Reducing CVC requirement, especially in AVF-eligible patients, is a key strategy to improve outcomes.