This prospective, multicenter observational study evaluates the impact of vascular access type on early mortality in patients aged ≥60 years initiating hemodialysis. Across an international cohort, the use of arteriovenous fistulas (AVF), as compared with central venous catheters (CVC), was associated with a significantly reduced risk of death within the first six months of treatment. Transition from CVC to AVF was also linked to improved survival, particularly among patients aged 60–74 years. These results highlight the importance of vascular access strategy in this population and support timely AVF creation, while reinforcing the need for individualized risk assessment.