OBJECTIVE: Arteriovenous fistulae (AVF) are necessary for hemodialysis in patients with end-stage kidney disease (ESKD) but are frequently complicated by thrombosis, stenosis, and need for revision. Glucagon-like peptide-1 receptor agonist (GLP-1RA) are increasingly used in type 2 diabetic patients with kidney disease, with recent evidence of both cardiovascular and renoprotective effects, yet their influence on AVF outcomes is unknown. The aim of this study was to investigate the impact of GLP-1RA on AVF outcomes in patients with ESKD.
METHODS: We conducted a multicenter, retrospective cohort study utilizing the TriNetX Research Network. This included 37,694 patients with ESKD who underwent open AVF creation from January 2017 to October 2022, with a minimum of one year follow-up. Patients started on new GLP-1RA therapy were matched 1:1 to non-GLP-1RA controls using propensity scores accounting for patient demographics, comorbidities, medication history, and diagnoses. Primary outcomes included the risk of fistula thrombosis, stenosis, infection, percutaneous angioplasty, and open revision over one year. Secondary outcomes included dialysis catheter intervention, major adverse cardiovascular events (MACE), and all-cause mortality. Cox proportional hazards regression and survival analyses were performed.
RESULTS: After matching, 1,239 well-matched pairs were created. Patients started on GLP-1RA therapy were associated with a lower risk of fistula thrombosis (HR, 0.77; 95% CI, 0.60-0.97; log-rank p=0.03), stenosis (HR, 0.82; 95% CI, 0.71-0.95; log-rank p=0.01), infection (HR, 0.61; 95% CI, 0.41-0.90; log-rank p=0.01), dialysis catheter intervention (HR, 0.63; 95% CI, 0.53-0.76; log-rank p<0.01), and open revision (HR, 0.57; 95% CI, 0.47-0.69; log-rank p<0.01) at one year. No significant effects were observed for percutaneous angioplasty (HR, 0.88; 95% CI, 0.75-1.05; log-rank p=0.15), MACE (HR, 0.99; 95% CI, 0.88-1.11; log-rank p=0.86), or all-cause mortality (HR, 0.79; 95% CI, 0.59-1.05; log-rank p=0.10. The protective effects of GLP-1RA were more prominent among male patients and in those with HgbA1c ≥7%, BMI ≥35 kg/m, or eGFR ≤30 mL/min/1.73 m. These protective effects were also seen as early as twelve weeks after AVF creation and persisted through three years, at which point GLP-1RA use was associated with improved survival (HR, 0.81; 95% CI, 0.68-0.96; log-rank p=0.02). 2 2
CONCLUSIONS: In patients with ESKD undergoing AVF creation, new GLP-1RA therapy was associated with reduced access complications, fewer dialysis catheter intervention, and improved long-term survival. These findings suggest that GLP-1RA use may promote a favorable environment following access creation, allowing AVF to mature.
