Arteriovenous Fistula Versus Central Venous Catheter: A Systematic Review of Impact on Quality of Life in Hemodialysis Patients

Introduction

End stage kidney disease (ESKD) is an increasing global health burden, with hemodialysis being one of the primary kidney replacement therapies. The primary goal of hemodialysis in ESKD patients is to prolong survival and improve overall quality of life.¹ Numerous studies have reported that patients undergoing dialysis tend to experience poorer health-related quality of life (HRQoL) than the general population. Consequently, HRQoL has emerged as a key outcome in the management of patients on hemodialysis.²

Vascular access is a critical determinant of hemodialysis success. The two most employed modalities are the arteriovenous fistula (AVF) and the central venous catheter (CVC). According to the Kidney Disease Outcomes Quality Initiative (KDOQI), AVFs are considered the gold standard for vascular access, as multiple studies have demonstrated their superiority in terms of long-term survival and lower complication rates. In contrast, CVCs are generally used as temporary access or in patients with limited vascular options. However, they are associated with higher risks of infection, thrombosis, and mortality.³ Despite these disadvantages, recent studies have suggested that CVC may be more appropriate in certain populations, particularly among elderly patients with limited life expectancy and multiple comorbidities, where the long-term benefits of AVFs may not be fully achieved.^4,5

Beyond clinical outcomes, vascular access plays a significant role in determining a patient’s HRQoL. The strong correlation between survival outcomes and quality of life highlights the importance of vascular access decisions in the overall treatment strategy. As such, the impact of vascular access type on both survival and HRQoL remains an important topic.⁶

Previous reviews have mainly focused on clinical outcomes like infection rates and survival, leaving HRQoL evidence less conclusive due to heterogeneity in populations, healthcare systems, socioeconomic contexts, and measurement tools. This systematic review synthesizes the current evidence on the comparative effects of AVF and CVC on HRQoL in patients on hemodialysis, addressing this gap to inform patient-centered vascular access decisions and enhance clinical strategies.

Methods

This research is a systematic review registered in the PROSPERO (number CRD420251068752). The protocol used in compiling this systematic review follows the guidelines of the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA).

Results

A total of 671 records were identified, of which 96 duplicates were removed. The remaining articles were then screened against our inclusion and exclusion criteria based on the abstract, resulting in 548 exclusions; 27 studies underwent full-text review, and ultimately, 15 eligible studies that satisfied all inclusion criteria were retained for the final analysis. Figure 1 illustrates the study selection process.

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Figure 1:

PRISMA flowchart of study selection.

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Risk of bias assessment

The critical appraisal results have been shown in Figure 2a and 2b. All 15 studies were judged to have an overall low risk of bias.

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Figure 2:

Risk of bias assessment using the Newcastle–Ottawa Scale for (a) cross-sectional studies, (b) cohort studies.

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Discussion

Vascular access is a critical determinant of hemodialysis outcomes, influencing survival through dialysis adequacy and complication risks, while also shaping HRQoL.⁶ Although HRQoL in hemodialysis patients is generally poor due to the chronic burden of disease, vascular access remains a fundamental factor affecting this outcome.¹²

The majority of included studies underscore the primacy of AVF over CVC in enhancing HRQoL, consistent with established guidelines such as the KDOQI “Fistula First” initiative.³ This is supported by the two prospective cohort studies (Kim et al. and Wasse et al.)^6,14, which provided longitudinal data showing sustained AVF benefits in domains like physical, mental, and kidney disease over 2 and 3-12 months. AVFs provide higher blood flow, improved dialysis adequacy, and lower risks of infections and inflammation, translating into fewer hospitalizations and better HRQoL across disease-specific (71.4%), physical (53.3%), mental (46.7%), and access-related domains (100%) [Table 2].

Heterogeneity in findings can be attributed to several factors, as stratified in Table 3. Demographic differences played a key role: Stronger AVF benefits were observed in younger cohorts (mean age <65 years; 100% favoring AVF) and Asian studies (83.3% favoring AVF), where CVC users often had worse laboratory profiles (e.g., higher CRP, lower albumin in studies like Kim et al. and Li et al.),^6,17 linking inflammation and nutritional deficits to poorer QoL [Supplementary Table S1].

In contrast, older cohorts (mean age ≥65 years; 25% favoring AVF) and European studies (60% favoring AVF) showed more neutral or CVC-favoring outcomes, potentially due to high comorbidity burdens. Younger patients tend to benefit more from AVF due to better vascular integrity, lower infection risk, and greater dialysis efficiency, which enhance both physical and mental QoL. Elderly patients with multiple comorbidities, such as diabetes or hypertension, experience higher AVF failure rates, making CVC a more practical option for immediate use and reduced discomfort.²³ Socioeconomic constraints, including low education and employment levels, may further diminish HRQoL differences between access types. Regionally, Asian studies reported stronger AVF benefits, possibly reflecting more efficient healthcare systems, healthier diets, and genetic factors associated with better vascular patency and lower complication rates.²⁴

A sensitivity analysis excluding the large Lopes et al. study (n=6,877) confirmed robustness, with 78.6% of remaining studies still favoring AVF.²¹

AVF demonstrated consistent superiority across all HRQoL domains, including kidney disease-specific, physical, mental, and vascular access-related aspects, as shown in Table 4 with mean differences favoring AVF over CVC. This advantage likely reflects lower infection, complication, and reoperation rates, as well as better efficacy and stability that reduce inflammation, hypotension, hospitalizations, daily disruptions, and anxiety about access failure. Consequently, AVF use promotes better cognitive function, social engagement, patient satisfaction, sleep quality, and overall well-being.^3,25

In the PCS domain, AVF benefits arise from fewer access-related complications that lessen hospitalizations and discomfort while supporting more reliable dialysis sessions that enhance physical functioning and reduce fatigue.^26,27 However, Maguire et al.¹² reported CVC superiority in “bodily pain” and “general health perception” among older, comorbid patients, diminishing AVF’s long-term benefits. A critical evaluation reveals methodological limitations: reliance on subjective SF-36/VAQ subscales without tools like the Visual Analog Scale (VAS), which may introduce recall bias.

In the MCS domain, AVF is linked to superior emotional well-being compared with CVC, as Büberci et al.²⁵ found higher anxiety, suspected depression, and poor sleep in CVC users, linked to elevated inflammation, poorer nutrition, physical discomfort, complications, emotional stress, and vulnerability.^28,29 Togay et al. reported an exception, with Non Tunneled Cuffed Catheter (NTCC) showing better role-emotional outcomes, although the small NTCC sample (n = 3) compared with the Tunneled Cuffed Catheter (TCC) (n = 31) and AVF (n = 63) groups suggests this may reflect sampling limitations rather than a true clinical advantage.¹⁹ In the context of vascular access, CVC tends to be favored in certain physical subdomains, as it requires no surgery or repeated punctures, thereby reducing pain and bleeding.¹⁶ Conversely, AVF is generally preferred for social functioning, particularly in activities such as bathing, since CVC use demands greater caution to prevent site infections, leading to restrictions and stress, whereas AVF eliminates these concerns.³⁰ CVC may, however, be more acceptable in terms of appearance, given its less invasive placement and minimal visible marks compared with AVF scars.³¹ In the domain of dialysis related complications, AVF remains preferred due to its lower hospitalization rates.³²

Although AVF remains the preferred access for better HRQoL and long-term outcomes, some patients may benefit more from CVC, such as older adults with limited life expectancy, severe comorbidities, frailty, poor vascular anatomy, high surgical risk, or urgent dialysis needs. CVC may also be preferred for short-term symptom relief or cosmetic reasons, as it avoids repeated needling and visible scars. However, only a few studies have shown advantages of CVC in select subdomains, with most reporting no significant differences due to small or unbalanced samples, limited measures, and broader psychosocial or socioeconomic factors.

This systematic review has several limitations. The dominance of cross-sectional designs limits inferences on causality and temporal relationships between vascular access and HRQoL changes. Substantial heterogeneity in populations, HRQoL tools, and outcome reporting precluded a full meta-analysis, justifying the narrative synthesis approach. The literature search was restricted to a few databases, excluding others such as Embase and Scopus. Additionally, reliance on one large study by Lopes et al.21 could skew overall findings, though sensitivity analysis mitigated this. Incomplete reporting of baseline variables restricted deeper subgroup analyses.21 Future research should employ prospective designs, standardized instruments, comprehensive database searches, and objective clinical metrics to address these gaps and improve generalizability.

This systematic review concludes that patients on hemodialysis with AVF access generally reported better overall HRQoL compared to those with CVC access. Additionally, AVF patients showed significant moderate improvements in specific domains, such as the kidney disease component, physical domain, mental domain, and vascular access-related domain. However, the variability in findings, with some studies reporting no significant differences or favoring CVC in specific domains, suggests that patient-specific factors, such as age, comorbidities, and socioeconomic context, might play a role in determining HRQoL.