Role of antiplatelet therapy in the durability of hemodialysis access

Background: Antiplatelet therapy (APT) is often used on anecdotal grounds to improve vascular access patency. The aim of this study was to assess the role of APT in hemodialysis (HD) patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement. Methods: All patients in a large HD vascular qualitative initiative database (2011–2017) were included and divided into no antiplatelet therapy (no-APT) vs. any APT [aspirin (ASA) or P2Y12 inhibitors (PI)]. Multivariate [logistic (MLR) and Cox (MCR) regression] analyses were used as appropriate. Results: A total of 24,847 patients undergoing HD access creation were identified (78% AVF). APT was noted among 49 and 46% of AVG and AVF patients, respectively. In MLR analysis, patients on no-APT vs. APT had a 12-fold increased risk of in-hospital mortality (odds ratio (OR) 11.79, [95% confidence interval 5.30–26.26]) and the risk of developing steal syndrome was higher among patients discharged on APT (OR 1.81, [1.19–2.76]). In patients undergoing AVF, primary patency (PP) was similar between APT and no-APT. However, in patients undergoing AVG, PP rates at 12 months were significantly higher for APT: ASA (47 vs. 41%) and PI (51 vs. 41%) than for no-APT (p = 0.008). At MCR analysis, the loss of PP at 12 months was 13% lower in ASA users (hazard ratio (HR) 0.87, [0.77–0.97], p = 0.02) and 24% lower in PI users (HR 0.76, [0.57–0.99], p = 0.046) compared to no-APT. Conclusion: In a large national database, we showed that antiplatelet therapy was associated with lower in-hospital mortality. Aspirin and P2Y12-inhibitor use among AVG patients demonstrated improved PP rates compared to no antiplatelet therapy. We recommend the use of antiplatelet therapy especially in patients on AVG.