SYSTEMIC IMMUNE-INFLAMMATION INDEX IS ASSOCIATED WITH VASCULAR ACCESS FAILURE IN PATIENTS UNDERGOING CHRONIC HEMODIALYSIS

Chronic Kidney Disease (CKD) is a major global health concern, affecting approximately 10% of the world’s population and contributing substantially to morbidity, mortality, and healthcare costs. In Indonesia, the prevalence of CKD was reported at 0.38% with hypertension, diabetes, and obesity identified as the main risk factors. The economic burden of CKD is considerable, with hemodialysis (HD) accounting for a large share of treatment costs. Hemodialysis remains the predominant renal replacement therapy worldwide, representing nearly 90% of dialysis treatments. Vascular access is critical for effective HD, with arteriovenous fistulas (AVF) recommended as the preferred option due to superior long-term outcomes. However, tunneled central venous catheters (tCVC) continue to be widely used, particularly when AVFs are not yet mature. Both access types face high failure rates: AVF failure rates of 20–50% within the first year and tCVC complications in 30–40% of patients annually. Access failure reduces dialysis adequacy, increases morbidity and mortality, and imposes substantial healthcare costs through repeated interventions such as angioplasty, thrombectomy, and surgical revision. Systemic inflammation plays a central role in the pathophysiology of vascular access failure, driving endothelial dysfunction, stenosis, and thrombosis. The Systemic Immune-Inflammation Index (SII), calculated as neutrophil × platelet / lymphocyte from routine blood counts, integrates information on innate inflammation, thrombotic potential, and adaptive immunity. High SII has been associated with worse outcomes in cardiovascular disease, malignancy, and chronic kidney disease. Given its simplicity, low cost, and wide availability, SII may serve as a practical biomarker for evaluating systemic inflammatory burden and its association with vascular access failure in chronic HD patients. This study aimed to evaluate the association between SII and vascular access failure in chronic hemodialysis patients.

We conducted an analytical cross-sectional study involving 80 chronic hemodialysis patients at the Hemodialysis Unit of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, between June and August 2025. Eligible participants were adults aged ≥18 years who had undergone hemodialysis for at least three months, with a minimum frequency of twice weekly, and were using either an arteriovenous fistula (AVF) or a tunneled central venous catheter (tCVC) as vascular access. Patients were excluded if they had active infection or fever ≥38°C within the past month, recent antibiotic use, immunosuppressant therapy within the previous three months, high-dose corticosteroid use within the past month, a diagnosis of malignancy, or if they declined participation. Vascular access failure was defined according to KDOQI 2019 criteria and included both historical events and dysfunction identified at the time of recruitment. Demographic, clinical, and comorbidity data were collected through interviews and medical records, and blood samples were obtained before dialysis sessions. The Systemic Immune-Inflammation Index (SII) was calculated from complete blood counts using the formula neutrophils × platelets / lymphocytes. Data were summarized as mean ± standard deviation or median with interquartile range for continuous variables and as frequencies and percentages for categorical variables. Between-group comparisons were made using the Mann–Whitney U test or Chi-square/Fisher’s exact test as appropriate. Discriminative ability of SII for vascular access failure was assessed with receiver operating characteristic (ROC) analysis, and the optimal cut-off was determined by the Youden index. Associations were examined using Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). Variables with p<0.25 in bivariate analysis were entered into multivariate models, with confounding assessed by >10% change between crude and adjusted PRs. A two-sided p-value <0.05 was considered statistically significant.

A total of 80 patients were enrolled, with a median age of 50 years (IQR 38–61); 57.5% were male. Hypertension was present in 87.5% of patients, and 33.8% had diabetes mellitus. The median duration of hemodialysis was 5 years (IQR 3–9). Vascular access type consisted of 41 patients (51.2%) with arteriovenous fistula (AVF) and 39 patients (48.8%) with tunneled central venous catheter (tCVC). Overall, vascular access failure was identified in 64 patients (80.0%), while 16 patients (20.0%) had no evidence of failure. By access type from 64 access failure patients, 28 (43,75%) AVF patients and 36 (56,25%) tCVC patients (56,25%). Patients with vascular access failure had significantly higher SII values than those without failure (median 722.25 [IQR 571.38–1034.9] vs 245.55 [IQR 196.5–400.85], p < 0.0001). Receiver operating characteristic (ROC) analysis demonstrated excellent discriminative ability of SII for vascular access failure, with an AUC of 0.947 (95% CI 0.887–1.000, p < 0.0001). The optimal cut-off value of SII was ≥495, which provided a sensitivity of 89.1% and specificity of 93.7%. When stratified by this threshold, 57 of 58 patients (98.3%) with SII ≥495 had vascular access failure, compared with 7 of 22 patients (31.8%) with SII <495. The crude prevalence ratio (PR) for vascular access failure with high SII was 3.089 (95% CI 1.674–5.699, p < 0.0001). In multivariate Poisson regression models adjusted for age, sex, obesity, and diabetes mellitus, the association remained significant with an adjusted PR of 3.083 (95% CI 1.669–5.697). None of the covariates altered the effect estimate by more than 10%.

In this cross-sectional study, higher SII values were independently associated with vascular access failure in chronic hemodialysis patients. SII, a simple and widely available biomarker derived from routine blood counts, demonstrated excellent discriminative ability for identifying patients with access dysfunction. These findings suggest that SII may serve as an biomarker parameter for vascular access risk evaluation, particularly in resource-limited settings. However, future multicenter and longitudinal studies are needed to confirm these associations and explore the role of SII in monitoring and prevention strategies for vascular access dysfunction.