Comparative outcomes of arteriovenous fistulas and grafts in haemodialysis: meta-analysis with subgroup analysis by fistula type and transposition status.

BACKGROUND

Arteriovenous fistulas (AVFs) are preferred over arteriovenous grafts (AVGs) for haemodialysis, but effectiveness may vary by fistula subtype, access site, and transposition.

METHODS

In this systematic review, PubMed, Web of Science, Scopus, and CENTRAL were searched up to 11 January 2025 for comparative studies of AVF versus AVG in adults. Random-effects meta-analyses pooled odds ratios (ORs) with 95% confidence intervals, standardized to 1-year outcomes (2-year effects summarized secondarily). Prespecified subgroups were AVF site (forearm versus upper arm), AVG site (forearm, upper arm, lower limb), AVF type (radiocephalic, brachiocephalic, brachiobasilic, basilic, brachial-brachial), and transposition. Observational studies were appraised with the National Institute of Health tool; randomized clinical trials with RoB 2. Meta-regression evaluated age, diabetes, and hypertension; certainty was appraised with GRADE.

RESULTS

Sixty-three studies (357 333 patients: 226 078 AVF; 131 255 AVG) were included. At 1 year, AVF was associated with higher primary (OR = 1.61, 95% confidence interval 1.19 to 2.18), primary-assisted (OR = 1.69, 1.46 to 1.96), and secondary patency (OR = 1.69, 1.18 to 2.44), and lower overall complications (OR = 0.52, 0.34 to 0.78) and mortality (OR = 0.57, 0.34 to 0.98) versus AVG; primary failure and revision did not differ. Benefits were marked for transposed AVFs (primary-assisted OR = 2.07, 1.45 to 2.95; complications OR = 0.62, 0.43 to 0.88) and for upper-arm AVFs in primary patency (OR = 1.56, 1.05 to 2.31). Basilic AVF improved secondary patency (OR = 2.31, 1.17 to 4.57). Infection and thrombosis risks were lower for basilic and brachiobasilic AVF and upper-arm AVF. Meta-regression suggested diabetes modified effects (better secondary patency; fewer revisions), whereas age and hypertension did not. Certainty was generally low to moderate.

CONCLUSION

When standardized at 1 year, AVFs outperform AVGs for patency, complications, and mortality, with magnitude varying by site, transposition, and fistula type. Findings support individualized access planning and the role of transposed upper-arm AVFs when feasible.

REGISTRATION NUMBER: CRD420251125422 (https://www.crd.york.ac.uk/PROSPERO/home).