Outcomes of initial hemodialysis vascular access in patients initiating dialysis with a tunneled catheter.

Our aim was to determine factors that influence time to removal of tunneled hemodialysis catheter (THC), probability of repeat vascular access creation, and time to repeat vascular access. The Optum Clinformatics Data Mart claims database was queried from 2011 to 2017 for patients who initiated hemodialysis with a THC. Time from initial arteriovenous fistula (AVF)/graft (AVG) to THC removal and time to repeat AVF/AVG were analyzed using Cox proportional hazards. The likelihood of repeat AVF/AVG was analyzed using logistic regression. A total of 8941 vascular access met the inclusion criteria: 6913 (77%) AVF and 2028 (23%) AVG. Median follow-up was 595 days among AVF patients (range, 1-2543 days) and 579 days among AVG patients (range, 1-2529 days). Patients undergoing AVF were younger, more likely to be male, of white race, and obese. Patients undergoing AVF were also slightly less likely to have diabetes, cardiac arrhythmia, congestive heart failure, and peripheral vascular disease than patients undergoing AVG. At 90 days and at 180 days after index access creation, significantly more patients who underwent index AVG had their THC removed compared with patients who underwent index AVF. By day 365, 78% of patients in both AVF and AVG had their THC removed. A total of 2550 (28.5%) patients underwent a repeat vascular access creation during the follow-up period: 30% of index AVF and 24% of index AVG. At 90 days, 180 days, and 365 days, significantly more patients in the index AVF group underwent a repeat vascular access creation than those in the index AVG group. Multivariate analysis demonstrated a significant interaction between vascular access type and age ≥70 years (P < .001) for time to THC removal, likelihood of repeat vascular access, and time to repeat vascular access. In the age <70 group, patients who underwent AVG were 60% more likely to have a shorter time to THC, had a 50.4% lower odds of repeat vascular access, and were 47% more likely to have a longer time to repeat vascular access compared with patients who underwent index AVF. In the age ≥70 group, patients who underwent AVG were 98% more likely to have a shorter time to THC removal, had 69.7% lower odds of repeat vascular access, and were 66% more likely to have a longer time to repeat vascular access. Creation of AVG vs AVF significantly decreases the time to THC removal in dialysis-dependent patients, with a larger difference in patients aged ≥70 vs <70. Initial AVG was associated with lower odds of repeat vascular access and longer time to repeat vascular access. These results suggest that the dictum of "fistula first" is not appropriate for all patient populations and supports judicious use of AVG in achieving the more recent shift toward "catheter last."

Copeland T ，Lawrence P ，Woo K 《-》

Association of Race and Ethnicity with Vascular Access Type Selection and Outcomes.

Black patients with end-stage renal disease (ESRD) represent 30.5% of the prevalent ESRD population in the United States, despite only accounting for 18% of the total population. Black patients are less likely to have pre-ESRD care compared with their white counterparts and are 3-4 times more likely to progress from chronic kidney disease to ESRD than whites, suggesting that black patients are particularly vulnerable to disparities in outcomes related to hemodialysis and ESRD. The objective of this study is to examine the association of race with outcomes of hemodialysis access and selection of arteriovenous fistula (AVF) versus arteriovenous graft (AVG). Patients with chronic kidney disease who initiated dialysis through a tunneled hemodialysis catheter (THC) were identified in the Optum's De-identified Clinformatics® Data Mart (OptumInsight, Eden Prairie, MN) claims database (2011-2017). The odds of AVF versus AVG creation and the odds of repeat vascular access creation were analyzed using logistic regression. Time from initial AVF/AVG to THC removal and time to repeat AVF/AVG were analyzed using Cox proportional hazards. About 7,584 vascular access patients met the inclusion criteria: 5,852 (77%) AVF and 1,732 (23%) AVG. Median follow-up was 583 days overall (range, 1-2,543), 589 days among AVF patients (range, 1-2,543), and 260 days among AVG patients (range, 1-2,529). Between races, there was no clinically significant variation in characteristics or comorbidities, with the exception of a much lower rate of obesity among Asians. Black patients had 36% lower odds of AVF index versus AVG index (P < 0.001). Patients 70 years or older and patients with diabetes had lower odds of AVF index, whereas men and obese patients had greater odds of receiving AVF. Overall, graft patients were 73% more likely to have a shorter time to THC removal than fistula patients, but Hispanic graft patients were 25% more likely to have a shorter time to THC removal than whites. Patients with diabetes, patients with cardiac arrhythmia, and obesity were more likely to have a longer time to THC removal. About 1,589 (21%) patients underwent a repeat vascular access creation during the follow-up period: 19% of whites (n = 802), 26% of blacks (n = 483), 19% of Hispanics (n = 250), and 19% of Asians (n = 54) (P < 0.001). Multivariate analysis demonstrated that black patients had 58% greater odds of requiring a second access than white patients (P < 0.001). Graft patients, patients 70 years or older, and men had lower odds of repeat access. Black patients were 45% more likely to have a shorter time until second access creation. Graft patients, patients aged 70 years or older, and men were more likely to have a longer time until second access. Patients with obesity were more likely to have a shorter time until second access. This study's findings suggest that after initial vascular access, compared with whites, blacks have no difference in time to index access success, but their access fails earlier and more frequently, independent of access type, age, and comorbidities. Given blacks constitute 30.5% of the hemodialysis population in the United States, it is imperative that future research investigate the root causes of these disparities.

Copeland TP ，Hye RJ ，Lawrence PF ，Woo K ... -  《-》

Arteriovenous grafts are associated with earlier catheter removal and fewer catheter days in the United States Renal Data System population.

Arteriovenous fistulas (AVFs) are associated with improved long-term outcomes but longer maturation times and higher primary failure rates compared with arteriovenous grafts (AVGs). The Fistula First Breakthrough Initiative has recently emphasized tunneled dialysis catheter (TDC) avoidance. We sought to characterize the relationship of AVFs and AVGs to the use of TDCs as well as secondary procedures. Using the United States Renal Data System (USRDS) database, we identified incident hemodialysis (HD) patients in 2005 that started HD with a TDC and survived at least 1 year. We then monitored them through 2008. Access creation, TDC removal, TDC placement, and secondary procedures were identified by Current Procedural Terminology codes (American Medical Association, Chicago, Ill). Multivariate logistic regression was used to identify risk factors for the primary end points. In 2005, HD was initiated in 56,495 patients, 74% with a TDC. Of these, 6286 had an access procedure ≤3 months and 1 year of follow-up (AVF, 4634; AVG, 1652). Mean age was 67.7 years (AVF, 67.3; AVG, 68.7 years; P < .001), 53.3% were men (AVF, 58.1%; AVG, 40.5%; P < .001), and 33.8% were obese (AVF, 33.6%; AVG, 34.4%; P = not significant). AVG placement was associated with a higher TDC removal at 1 (7.9% vs 3.1%; P < .001), 3 (47.8% vs 17.8%; P < .001), and 6 (60.6% vs 47.2%; P < .001) months. There was no difference at 9 months (AVG, 64.9% vs AVF, 62.3%; P = .06). The median time to TDC removal was lower in the AVG group (70 days vs 155 days; P < .001). Multivariable model found AVFs were associated with decreased odds of TDC removal at 3 (odds ratio, 0.22; P < .001) and 6 months (odds ratio, 0.54; P < .001). AVGs required more secondary procedures than AVFs at all time points up to 1 year and specifically had increased thrombectomy procedures (39.8% vs 11.5%; P < .001). In patients starting dialysis with a TDC, AVGs are associated with increased TDC removal and fewer catheter days compared with AVFs at up to 6 months. However, AVGs require more secondary procedures at all time points up to 1 year.

Leake AE ，Yuo TH ，Wu T ，Fish L ，Dillavou ED ，Chaer RA ，Leers SA ，Makaroun MS ... -  《-》

Surgical and endovascular assisted maturation procedures improve cannulation after arteriovenous fistula creation, but not after arteriovenous graft placement.

Hafeez MS ，Chaer RA ，Eslami MH ，Abdul-Malak OM ，Yuo TH ... -  《-》

Patients started on hemodialysis with tunneled dialysis catheter have similar survival after arteriovenous fistula and arteriovenous graft creation.

Current guidelines suggest that arteriovenous fistula (AVF) is associated with survival advantage over arteriovenous graft (AVG). However, AVFs often require months to become functional, increasing tunneled dialysis catheter (TDC) use, which can erode the benefit of an AVF. We sought to compare survival in patients with end-stage renal disease after creation of an AVF or AVG in patients starting hemodialysis (HD) with a TDC and to identify patient populations that may benefit from preferential use of AVG over AVF. Using U.S. Renal Data System databases, we identified incident HD patients in 2005 through 2008 and observed them through 2008. Initial access type and clinical variables including albumin levels were assessed using U.S. Renal Data System data collection forms. Attempts at AVF and AVG creation in patients who started HD through a TDC were identified by Current Procedural Terminology codes. We accounted for the effect of changes in access type by truncating follow-up when an additional AVF or AVG was performed. Survival curves were then constructed, and log-rank tests were used for pairwise survival comparisons, stratified by age. Multivariate analysis was performed with Cox proportional hazards regressions; variables were chosen using stepwise elimination. An interaction of access type and albumin level was detected, and Cox models using differing thresholds for albumin level were constructed. The primary outcome was survival. Among the 138,245 patients who started with a TDC and had complete records amenable for analysis, 22.8% underwent AVF creation (mean age ± standard deviation, 68.9 ± 12.5 years; 27.8% mortality at 1 year) and 7.6% underwent AVG placement (70.2 ± 12.0 years; 28.2% mortality) within 3 months of HD initiation; 69.6% remained with a TDC (63.2 ± 15.4 years; 33.8% mortality). In adjusted Cox proportional hazards regression, AVF creation is equivalent to AVG placement in terms of survival (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.93-1.02; P = .349). AVG placement is superior to continued TDC use (HR, 1.54; 95% CI, 1.48-1.61; P < .001). In patients older than 80 years with albumin levels >4.0 g/dL, AVF creation is associated with higher mortality hazard compared with AVG creation (HR, 1.22; 95% CI, 1.04-1.43; P = .013). For patients who start HD through a TDC, placement of an AVF and AVG is associated with similar mortality hazard. Further study is necessary to determine the ideal access for patients in whom the survival advantage of an AVF over an AVG is uncertain.

Yuo TH ，Chaer RA ，Dillavou ED ，Leers SA ，Makaroun MS ... -  《-》