Predictors of delayed transition from central venous catheter use to permanent vascular access among ESRD patients

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

Vascular access type and mortality in elderly incident hemodialysis patients

INTRODUCTION

The ideal vascular access type for elderly hemodialysis (HD) patients remains debatable. The aim of this study was to analyze the association between patterns of vascular access use within the first year of HD and mortality in elderly patients.

METHODS

Single-center retrospective study of 99 incident HD patients aged≥80 years from January 2010 to May 2021. Patients were categorized according to their patterns of vascular access use within the first year of HD: central venous catheter (CVC) only, CVC to arteriovenous fistula (AVF), AVF to CVC, and AVF only. Baseline clinical data were compared among groups. Survival outcomes were analyzed using Kaplan-Meier survival curves and Cox's proportional hazards model.

RESULTS

When compared with CVC to AVF, mortality risk was significantly higher among CVC only patients and similar to AVF only group [HR 0.93 (95% CI 0.32-2.51)]. Ischemic heart disease [HR 1.74 (95% CI 1.02-2.96)], lower levels of albumin [HR 2.16 (95% CI 1.28-3.64)] and hemoglobin [HR 4.10(95% CI 1.69-9.92)], and higher levels of c-reactive protein [HR 1.87(95% CI 1.11-3.14)] were also associated with increased mortality risk in our cohort, p<0.05.

CONCLUSION

Our findings suggested that placement of an AVF during the early stages of dialysis was associated with lower mortality compared to persistent CVC use among elderly patients. AVF placement appears to have a positive impact on survival outcomes, even in those who started dialysis with a CVC.

Delay in Permanent Vascular Access Formation and Referral to a Nephrologist in Incident Hemodialysis Patients: A Single Center Experience

OBJECTIVE

 This study assessed the factors associated with delayed referral to a nephrologist and delay in formation of a permanent vascular access in incident hemodialysis (HD) patients.

METHODS

 This prospective cross-sectional study was conducted from February 2021 to July 2021 on end stage renal disease (ESRD) patients receiving maintenance hemodialysis (MHD) at our center. Data were collected at the bedside during the HD session about a referral to a nephrologist, about when they were asked for permanent vascular access formation and the reason for the delay in its formation.  Results: Out of 296 patients recruited in our study, 168 (56.8%) were male and 128 (43.2) were female. The mean age was 53.5±15 years (minimum of 19 years and maximum of 90 years). The most common reason for refusal of making permanent vascular access [arterio-venous fistula (AVF) or arterio-venous graft (AVG)] was fear of pain in our patients 65 (43.3%) followed by the denial of the disease 32 (21.3%). Among the study subjects, 231 (78%) patients were referred to the nephrologist immediately or within one month of their diagnosis. Some 152 (51.4%) of the patients were not in favor of making AVF whereas 151 (51%) refused for starting HD, hence most of our patients 181 (61.1%) initiated HD in emergency by a central venous catheter (CVC).

CONCLUSION

 Early referral should be done by primary care physicians (PCPs) for the timely management of CKD patients. As CKD is a progressive disease, it requires special attention by a nephrologist for adjustment of patient's medications, timely follow-up, counseling, the early formation of AVF for HD, and planning for renal transplant. In our study, the majority of our patients initiated their HD via CVC because of the delayed visit to a nephrologist. Most patients were asked for AVF formation on the same day of presentation to our nephrology unit as they had advanced CKD (Stage 5) 134 (51.4%). Most patients in our study delayed AVF formation 152 (51.4%). With timely referral to a nephrologist, the nephrologist will be able to do better and repeated counseling about the disease, its progression, and the need for permanent vascular access for initiation of HD while patients and their families will get more time to make decisions.

Research Priorities for Percutaneous Arteriovenous Fistula Creation in Patients with End-Stage Renal Disease: Proceedings and Recommendations from a Multidisciplinary Research Consensus Panel

Recently developed endovascular techniques to create percutaneous arteriovenous fistulas are an alternative to surgical arteriovenous fistula creation, although there is currently a lack of high-level evidence regarding their creation, maturation, utilization, and long-term function. Recognizing this, the Society of Interventional Radiology Foundation sponsored a Research Consensus Panel and Summit for the prioritization of a research agenda to identify and address the gaps in current knowledge.

Vascular access placement and mortality in elderly incident hemodialysis patients

BACKGROUND

Arteriovenous fistulas (AVFs) are the preferred vascular access type in most hemodialysis patients. However, the optimal vascular access type in octogenarians and older (≥80 years) hemodialysis patients remains widely debated given their limited life expectancy and lower AVF maturation rates.

METHODS

Among incident hemodialysis patients receiving care in a large national dialysis organization during 2007-2011, we examined patterns of vascular access type conversion in 1 year following dialysis initiation in patients <80 versus ≥80 years of age. Among a subcohort of patients ≥80 years of age, we examined the association between vascular access type conversion and mortality using multivariable survival models.

RESULTS

In the overall cohort of 100 804 patients, the prevalence of AVF/arteriovenous graft (AVG) as the primary vascular access type increased during the first year of hemodialysis, but plateaued thereafter. Among 8356 patients ≥80 years of age and treated for >1 year, those with initial AVF/AVG use and placement of AVF from a central venous catheter (CVC) had lower mortality compared with patients with persistent CVC use. When the reference group was changed to patients who had AVF placement from a CVC in the first year of dialysis, those with initial AVF use had similar mortality. A longer duration of CVC use was associated with incrementally worse survival.

CONCLUSIONS

Among incident hemodialysis patients ≥80 years of age, placement of an AVF from a CVC within the first year of dialysis had similar mortality compared with initial AVF use. Our data suggest that initial CVC use with later placement of an AVF may be an acceptable option among elderly hemodialysis patients.

Maturation of arteriovenous fistulas in patients with and without preexisting hemodialysis catheters

Background

Central venous catheter (CVC) placement has been linked to systemic inflammation. This study was conducted to compare the successful maturation of arteriovenous fistulas (AVFs) and the preoperative white blood cell (WBC) profiles between patients with and without preexisting CVCs.

Materials and methods

A retrospective cohort study was conducted with 550 patients who underwent first-time AVF creation. Patients were divided into three groups according to preexisting CVCs and CVC types as follows: tunneled CVC (n = 23), nontunneled CVC (n = 223), and no CVC (n = 304). These three groups were compared in terms of AVF maturation and preoperative WBC profiles.

Results

The mean age of the patients was 61.1 ± 14.3 years. The AVF maturation rates of the tunneled CVC, nontunneled CVC and no CVC groups were 65.2%, 54.7% and 74.7%, respectively (p < 0.001). According to the uni- and multivariate analyses, only the nontunneled CVC group had a lower odds of AVF maturation compared to the no CVC group (adjusted odds ratio 0.43; 95% confidence interval 0.29–0.62). Patients with preexisting nontunneled CVC but not tunneled CVC also had significantly higher mean WBC and neutrophil counts but a lower percentage of lymphocytes than patients with no preexisting CVC.

Conclusion

Preexisting nontunneled CVC had a negative impact on the successful maturation of the newly created AVF. Patients in the nontunneled CVC group had the highest preoperative WBC and neutrophil counts but the lowest lymphocyte percentage compared to patients in the other two groups.

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Nontunneled CVC has a negative impact on the successful maturation of AVF.

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AVF maturation could be affected by duration of CVC placement.

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Preexisting nontunneled CVC is significantly related to high preoperative WBC count.

Maturing arteriovenous accesses in incident haemodialysis patients and first-year outcomes

INTRODUCTION

Nephrologists have increased arteriovenous access placement in patients with chronic kidney disease. Not yet usable 'maturing' arteriovenous fistulas and grafts are nearly as common as mature arteriovenous fistulas or grafts. Little has been reported about patients initiating haemodialysis with unready arteriovenous fistulas or grafts.

METHODS

The United States Renal Data System records for all adult patients initiating haemodialysis with central venous catheters between July 2010 and December 2011. Patients were categorized by whether a maturing arteriovenous fistula or graft was present. Transition to working arteriovenous fistula or graft was determined from linked Medicare claims. Modality changes and survival were ascertained. A logistic model for one-year survival and a subdistribution hazards model for transition to working arteriovenous fistula or graft, accounting for the competing risk of death, were constructed.

RESULTS

Compared to central venous catheter-only, maturing arteriovenous fistula or graft was associated with access conversion (hazard ratio = 2.23 (2.17-2.30) and 3.25 (2.97-3.56), respectively, p < 0.001 for both). Median time to conversion, among those who transitioned, was 95 days (interquartile range = 56-139) for patients with a maturing arteriovenous graft and 135 days (98-198) with a maturing arteriovenous fistula, versus 193 days (138-256) with central venous catheter-only. Pre-dialysis nephrology care, male sex and non-Caucasian race were associated with access conversion. Patients without a maturing arteriovenous fistula or graft had decreased odds of one-year survival (odds ratio = 0.61 (0.58-0.66), p < 0.001), which attenuated with adjustment for access conversion (adjusted odds ratio = 1.06 (0.98-1.13), p = 0.2).

CONCLUSION

Maturing arteriovenous fistulas or grafts were associated with enhanced first-year survival and increased opportunity for working arteriovenous fistulas or grafts, which may reflect pre-dialysis decision-making, quality of care and comorbid diseases. Central venous catheter exposure was substantial, even among patients with maturing access. Contributory factors prolonging conversion to arteriovenous access need to be identified and addressed.

Elderly patient: which vascular access? Choice and management of vascular access in the elderly patient

The optimal vascular access for elderly patients remains a challenge due to the difficult balance between risks and benefits in a population with increased comorbidity and decreased survival. Long dependence to central vein catheter, patient comorbidities, life expectancy, and complication rates are important influencing the indications for arteriovenous fistula or an arteriovenous graft. Although central vein catheters are simpler way to start a hemodialysis treatment, elderly patients are also at higher risk of death from infection or other complications associated with them more than for younger patients. The discussion revolves around the following key questions:

What are the limiting factors for a vascular access in the elderly patients? Central venous catheter—is it still an option for elderly patients? Is still the autologous arteriovenous fistula playing a pivotal role as hemodialysis access in the elderly patients? Are there any real surgical contraindication to perform a vascular access in elderly patients? Is the old age a limiting factor for the vascular access management?

Graft for Immediate use as First Stage of a Native Fistula

The majority of patients in the United States begin hemodialysis with a catheter. Many have immature or inadequate fistulae. At 90 days 77% of these patients are still using a catheter or a graft. The morbidity and mortality from prolonged catheter use have been well delineated. Although most of us adhere to the DOQI and Fistula First tenets, a fistula at all costs can seem counterproductive. A new paradigm is needed. The techniques described in this paper offer a novel approach to circumvent the problems of increasing catheter use and long fistula maturation times. The graft for immediate use is placed in the forearm and allows the proximal vessels to mature while providing dialysis access without a catheter. When these vessels meet maturation guidelines, or when surveillance indicates impending graft failure, a native fistula can be constructed and used in a 2–3 week period. This approach minimizes or circumvents catheter use altogether.

Interventions for treating central venous haemodialysis catheter malfunction

BACKGROUND

Adequate haemodialysis (HD) in people with end-stage kidney disease (ESKD) is reliant upon establishment of vascular access, which may consist of arteriovenous fistula, arteriovenous graft, or central venous catheters (CVC). Although discouraged due to high rates of infectious and thrombotic complications as well as technical issues that limit their life span, CVC have the significant advantage of being immediately usable and are the only means of vascular access in a significant number of patients. Previous studies have established the role of thrombolytic agents (TLA) in the prevention of catheter malfunction. Systematic review of different thrombolytic agents has also identified their utility in restoration of catheter patency following catheter malfunction. To date the use and efficacy of fibrin sheath stripping and catheter exchange have not been evaluated against thrombolytic agents.

OBJECTIVES

This review aimed to evaluate the benefits and harms of TLA, preparations, doses and administration as well as fibrin-sheath stripping, over-the-wire catheter exchange or any other intervention proposed for management of tunnelled CVC malfunction in patients with ESKD on HD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 17 August 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

We included all studies conducted in people with ESKD who rely on tunnelled CVC for either initiation or maintenance of HD access and who require restoration of catheter patency following late-onset catheter malfunction and evaluated the role of TLA, fibrin sheath stripping or over-the-wire catheter exchange to restore catheter function. The primary outcome was be restoration of line patency defined as ≥ 300 mL/min or adequate to complete a HD session or as defined by the study authors. Secondary outcomes included dialysis adequacy and adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed retrieved studies to determine which studies satisfy the inclusion criteria and carried out data extraction. Included studies were assessed for risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using GRADE.

MAIN RESULTS

Our search strategy identified 8 studies (580 participants) as eligible for inclusion in this review. Interventions included: thrombolytic therapy versus placebo (1 study); low versus high dose thrombolytic therapy (1); alteplase versus urokinase (1); short versus long thrombolytic dwell (1); thrombolytic therapy versus percutaneous fibrin sheath stripping (1); fibrin sheath stripping versus over-the-wire catheter exchange (1); and over-the-wire catheter exchange versus exchange with and without angioplasty sheath disruption (1). No two studies compared the same interventions. Most studies had a high risk of bias due to poor study design, broad inclusion criteria, low patient numbers and industry involvement.Based on low certainty evidence, thrombolytic therapy may restore catheter function when compared to placebo (149 participants: RR 4.05, 95% CI 1.42 to 11.56) but there is no data available to suggest an optimal dose or administration method. The certainty of this evidence is reduced due to the fact that it is based on only a single study with wide confidence limits, high risk of bias and imprecision in the estimates of adverse events (149 participants: RR 2.03, 95% CI 0.38 to 10.73).Based on the available evidence, physical disruption of a fibrin sheath using interventional radiology techniques appears to be equally efficacious as the use of a pharmaceutical thrombolytic agent for the immediate management of dysfunctional catheters (57 participants: RR 0.92, 95% CI 0.80 to 1.07).Catheter patency is poor following use of thrombolytic agents with studies reporting median catheter survival rates of 14 to 42 days and was reported to improve significantly by fibrin sheath stripping or catheter exchange (37 participants: MD -27.70 days, 95% CI -51.00 to -4.40). Catheter exchange was reported to be superior to sheath disruption with respect to catheter survival (30 participants: MD 213.00 days, 95% CI 205.70 to 220.30).There is insufficient evidence to suggest any specific intervention is superior in terms of ensuring either dialysis adequacy or reduced risk of adverse events.

AUTHORS' CONCLUSIONS

Thrombolysis, fibrin sheath disruption and over-the-wire catheter exchange are effective and appropriate therapies for immediately restoring catheter patency in dysfunctional cuffed and tunnelled HD catheters. On current data there is no evidence to support physical intervention over the use of pharmaceutical agents in the acute setting. Pharmacological interventions appear to have a bridging role and long-term catheter survival may be improved by fibrin sheath disruption and is probably superior following catheter exchange. There is no evidence favouring any of these approaches with respect to dialysis adequacy or risk of adverse events.The current review is limited by the small number of available studies with limited numbers of patients enrolled. Most of the studies included in this review were judged to have a high risk of bias and were potentially influenced by pharmaceutical industry involvement.Further research is required to adequately address the question of the most efficacious and clinically appropriate technique for HD catheter dysfunction.

Vascular Access Placement Order and Outcomes in Hemodialysis Patients: A Longitudinal Study

BACKGROUND

Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled "permanent" for AV fistulas (AVF) or grafts (AVG) and "temporary" for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement.

METHODS

All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age.

RESULTS

In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments.

CONCLUSIONS

HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a "permanent" vascular access and used an AVA for the majority of HD treatments.

Optimal timing for vascular access creation

Many guidelines recommend that end-stage renal disease (ESRD) patients should have a permanent vascular access, preferably an autologous arteriovenous fistula (AVF), at the start of renal replacement therapy. Nevertheless, a large proportion of patients still start hemodialysis with a central venous catheter (CVC). On the other hand, there are increasing numbers of patients in whom an AVF has been created, but who never actually end up on dialysis, as well as a substantial number of patients in whom creation of a vascular access has been attempted unsuccessfully.To improve this situation, timely exploration to assess suitability for and creation of preemptive AVF should be promoted. Decision to construct an AVF should depend on the likelihood and rate of progression to ESRD. For this goal, some reliable prediction models are available. Also, the likelihood that such an attempt will result in a successful outcome should be taken into account, but suitable validated models to accurately make such estimates are lacking. Next to patient-specific factors, some local conditions such as easy access to a vascular surgeon should also be incorporated in the decision-making process between the nephrology team and the patient.

Hemodialysis vascular access and clinical outcomes: an observational multicenter study

Background

Arteriovenous fistula (AVF) is the optimal vascular access in hemodialysis (HD) patients because of its lower complication rates and better longevity compared to arteriovenous graft (AVG) and central venous catheter (CVC).

Methods

A cohort of 532 HD patients from nine HD facilities were recruited in September 2012 and prospectively followed for a median of 28 months. Unadjusted and fully adjusted hazard ratios (HR) of mortality for vascular access were calculated using Cox proportional hazards model.

Results

Seventy-two percent of patients had AVF, 7% AVG, 21% CVC. Overall, AVF failure was 43 per 1000 patient-years and AVF creation 19 per 1000 patient-years. In logistic regression analysis, odds ratio of having non-AVF access for age was 1.02 (95% CI: 1.01-1.03), female gender 1.97 (95% CI: 1.30-3.01), and Charlson comorbidity index (CCI) 1.17 (95% CI: 1.02-1.36). Total number of deaths was 17 per 100 patient-years. Two percent of death was because of pure catheter infection and 10.5% more mortality happened due to catheter infection complicated by underlying cardiovascular diseases. In unadjusted and full adjustment Cox models, HR of death for patients with CVC (reference: AVF patients) was, respectively, 2.17 (95% CI: 1.51-3.11) and 1.58 (95% CI: 1.01-2.51). Access problems of insertion-repair accounted for 24% of hospitalization, and catheter infection explained 10% of total admissions.

Conclusions

Catheter use in HD patients was associated with higher mortality and morbidity despite extensive adjustment for covariates. Risk factors for higher usage of non-AVF access are older age, female gender, and underlying comorbidities.

Factors Affecting Hemodialysis Adequacy in Cohort of Iranian Patient with End Stage Renal Disease

BACKGROUND

There are many factors that can affect dialysis adequacy; such as the type of vascular access, filter type, device used, and the dose, and rout of erythropoietin stimulation agents (ESA) used. The aim of this study was investigating factors affecting Hemodialysis adequacy in cohort of Iranian patient with end stage renal disease (ESRD).

METHODS

This is a cross-sectional study conducted on 133 Hemodialysis patients referred to two dialysis units in Sistan-Baluchistan province in the cities of Zabol and Iranshahr, Iran. We have looked at, (the effects of the type of vascular access, the filter type, the device used, and the dose, route of delivery, and the type of ESA used) on Hemodialysis adequacy. Dialysis adequacy was calculated using kt/v formula, two-part information questionnaire including demographic data which also including access type, filter type, device used for hemodialysis (HD), type of Eprex injection, route of administration, blood groups and hemoglobin response to ESA were utilized. The data was analyzed using the SPSS v16 statistical software. Descriptive statistical methods, Mann-Whitney statistical test, and multiple regressions were used when applicable.

RESULTS

The range of calculated dialysis adequacy is 0.28 to 2.39 (units of adequacy of dialysis). 76.7% of patients are being dialyzed via AVF and 23.3% of patients used central venous catheters (CVC). There was no statistical significant difference between dialysis adequacy, vascular access type, device used for HD (Fresenius and B. Braun), and the filter used for HD (p> 0.05). However, a significant difference was observed between the adequacy of dialysis and Eprex injection and patients' time of dialysis (p <0.05).

CONCLUSION

Subcutaneous ESA (Eprex) injection and dialysis shift (being dialyzed in the morning) can have positive impact on dialysis adequacy. Patients should be educated on the facts that the type of device used for HD and the vascular access used has no significant effects on dialysis adequacy.

The importance of success prediction in angioaccess surgery

Access to the circulation is an "Achilles' heel" of chronic hemodialysis. According to the current guidelines, autologous arteriovenous fistula is the best choice available. However, the impossibility of immediate use and the high rate of non-matured fistulas place fistula far from an ideal hemodialysis vascular access. The first attempt at constructing an angioaccess should result in functional access as much as possible. After failed attempts, patients and nephrologists lose their patience and confidence, which results in high percentage of central venous catheter use. Predictive models could help, but clinical judgment still remains crucial. Early referral to the nephrologist and vascular access surgeon, careful preoperative examinations, preparation of patients and duplex sonography mapping of the vessels are very important in the preoperative stage. In the operative stage, it is crucial to understand that angioaccess procedures should not be considered as minor procedures and these operations must be performed by surgeons with demonstrable interest and experience. In the postoperative stage, appropriate surveillance of the maturation process is also important, as well as good cannulation skills of the dialysis staff. The purpose of this review article is to stress the importance of success prediction in order to avoid unsuccessful attempts in angioaccess surgery.

Comparison of treatment delay associated with tunneled hemodialysis catheter placement between interventionists

BACKGROUND/AIMS

Fragmented care in nephrology can cause treatment delays. Nephrologists are qualified to perform vascular access-related procedures because they understand the pathophysiology of renal disease and perform physical examination for vascular access. We compared treatment delays associated with tunneled hemodialysis catheter (TDC) placement between interventional radiologists and nephrologists.

METHODS

We collected data by radiologists from January 1, 2011 through December 31, 2011 and by nephrologists from since July 1, 2012 through June 30, 2013. We compared the duration from the hemodialysis decision to TDC placement (D-P duration) and hemodialysis initiation (D-H duration), catheter success and the complication rate, and the frequency and the usage time of non-tunneled hemodialysis catheters (NDCs) before TDC placement.

RESULTS

The study analyzed 483 placed TDCs: 280 TDCs placed by radiologists and 203 by nephrologists. The D-P durations were 319 minutes (interquartile range [IQR], 180 to 1,057) in the radiologist group and 140 minutes (IQR, 0 to 792) in the nephrologist group. Additionally, the D-H durations were 415 minutes (IQR,260 to 1,091) and 275 minutes (IQR, 123 to 598), respectively. These differences were statistically significant (p = 0.00). The TDC success rate (95.3% vs. 94.5%, respectively; p = 0.32) and complication rate (16.2% vs. 11%, respectively; p = 0.11) did not differ between the groups. The frequency (24.5 vs. 26%, respectively; p = 0.72) and the usage time of NDC (8,451 vs. 8,416 minutes, respectively; p = 0.91) before TDC placement were not statistically significant.

CONCLUSIONS

Trained interventional nephrologists could perform TDC placement safely, minimizing treatment delays.

Hemodialysis arteriovenous fistula as first option not necessary in elderly patients

OBJECTIVE

Kidney Disease Outcomes Quality Initiative guidelines recommend arteriovenous fistulas as the preferred access for hemodialysis patients. However, this may not hold across all populations of patients, especially the elderly, given their comorbidities and relatively reduced life expectancy. Therefore, we investigated whether fistulas held benefit over arteriovenous grafts as hemodialysis access in elderly patients.

METHODS

We retrospectively searched a vascular access database to compare the outcomes for 138 fistulas and 44 grafts that were placed in elderly patients (≥75 years old) during a 4-year period at a tertiary medical center.

RESULTS

The primary failure rate was higher for the fistulas compared with the grafts (odds ratio, 2.89; P = .008), and more fistulas required one or more interventions before their successful use compared with grafts (31% vs 10%, respectively; P = .03). In addition, the time to catheter-free dialysis was longer for fistulas than for grafts (P < .001). However, the primary and secondary patency rates were comparable between the fistulas and grafts and between the different access locations. The all-cause mortality rates were also comparable between the fistula and graft groups.

CONCLUSIONS

Despite the Fistula First Initiative recommendations, grafts need not be discounted as a first-line hemodialysis access option in select elderly patients.

Analysis of Vascular Access in Haemodialysis Patients - Single Center Experience

BACKGROUND

Vascular access is the key in successful management of chronic haemodialysis (HD) patients. Though native arteriovenous fistula (AVF) is considered the access of choice, many patients in our country initiate haemodialysis through central venous catheter (CVC). There is paucity of data on vascular access in haemodialysis patients from southern India.

AIM

Aim of the present study was to review our experience of vascular access in Haemodialysis patients (both central venous catheters and arteriovenous fistula) and to assess its success rate and common complications.

MATERIALS AND METHODS

This prospective study was conducted between January 2014 and December 2014 in our institute. A total of 50 patients with Chronic Kidney Disease (CKD) underwent vascular access intervention during the above period.

RESULTS

A temporary venous catheter (96%) in the right internal jugular vein was the most common mode of initiation of haemodialysis with 34.48% incidence of catheter related sepsis. Fifty percent of catheters were removed electively with mean duration of catheter survival of 77.23 ± 14.8 days. Wrist AVF (60%) was the most common site of AVF creation followed by arm (30%), mid-forearm (7.5%) and leg (2.5%). Complications include distal oedema (17.5%) and venous hypertension (2.5%). Primary failure occurred in 25% of patients and was more common in diabetic, elderly (>60 years) and in distal fistulas. Elderly patients (>60 years) starting dialysis with a CVC were more likely to be CVC dependent at 90 days.

CONCLUSION

Late presentation and delayed diagnosis of chronic kidney disease (CKD) necessitates dialysis initiation through temporary catheter. Dialysis catheter with its attendant complications further adds to the morbidity, mortality, health care burden and costs. Early nephrology referral and permanent access creation in the pre dialysis stage could avert the unnecessary complications and costs of catheter.

Vascular access for incident hemodialysis patients in Catalonia: analysis of data from the Catalan Renal Registry (2000-2011)

Purpose

Arteriovenous fístula is the best vascular access (VA) for hemodialysis. We analyzed the VA used at first session and the factors associated with the likelihood to start hemodialysis by fistula in 2000-2011.

Methods

Data of VA type were obtained in 9,956 incident hemodialysis patients from the Catalan Registry.

Results

Overall, 47.9% of patients initiated hemodialysis with a fistula, 1.2% with a graft, 15.9% with a tunneled catheter and 35% with an untunneled catheter. The percentage of incident patients with fistula and catheter has remained stable at around 50% over the years. The likelihood to start hemodialysis with fistula was significantly lower in females [adjusted odds ratio: 0.69, 95% confidence interval (CI): 0.61-0.75], patients aged 18-44 years (0.78, 95% CI: 0.64-0.94), patients with comorbidity (0.67, 95% CI: 0.60-0.75) and tended to be lower in patients aged over 74 years (0.89, 95% CI: 0.78-1.01). The probability to use fistula was significantly higher in patients with polycystic kidney disease (2.08, 95% CI: 1.63-2.67), predialysis nephrology care longer than 2 years (4.14, 95% CI: 3.63-4.73) and steady chronic kidney disease (CKD) progression (10.97, 95% CI: 8.41-14.32). During 1 year of follow-up, 67.2% and 59.6% of patients using untunneled and tunneled catheter changed to fistula, respectively.

Conclusions

Starting hemodialysis by fistula was related with nonmodifiable patient characteristics and modifiable CKD practice processes, such as predialysis care duration. Half of the incident patients were exposed annually in Catalonia to potential catheter complications. This scenario can be improved by optimizing the processes of CKD care.

Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients

Young blacks receiving dialysis have an increased risk of death compared with whites in the United States. Factors influencing this disparity among the young adult dialysis population have not been well explored. Our study examined the relation of neighborhood socioeconomic status (SES) and racial differences in mortality in United States young adults receiving dialysis. We merged US Renal Data System patient-level data from 11,027 black and white patients ages 18-30 years old initiating dialysis between 2006 and 2009 with US Census data to obtain neighborhood poverty information for each patient. We defined low SES neighborhoods as those neighborhoods in U.S. Census zip codes with ≥20% of residents living below the federal poverty level and quantified race differences in mortality risk by level of neighborhood SES. Among patients residing in low SES neighborhoods, blacks had greater mortality than whites after adjusting for baseline demographics, clinical characteristics, rurality, and access to care factors. This difference in mortality between blacks and whites was significantly attenuated in higher SES neighborhoods. In the United States, survival between young adult blacks and whites receiving dialysis differs by neighborhood SES. Additional studies are needed to identify modifiable factors contributing to the greater mortality among young adult black dialysis patients residing in low SES neighborhoods.

Race, ethnicity, and state-by-state geographic variation in hemorrhagic stroke in dialysis patients

BACKGROUND AND OBJECTIVES

Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Medicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios (ARRs) for stroke.

RESULTS

A total of 265,685 Medicare-eligible incident dialysis patients were studied. During a median follow-up of 15.5 months, 2397 (0.9%) patients sustained a hemorrhagic stroke. African Americans (ARR, 1.43; 95% confidence interval [CI], 1.30 to 1.57), Hispanics (ARR, 1.78; 95% CI, 1.57 to 2.03), and individuals of other races (ARR, 1.51; 95% CI, 1.26 to 1.80) had a significantly higher risk for hemorrhagic stroke compared with whites. In models adjusted for age and sex, four states had O/E ARRs for hemorrhagic stroke that were significantly greater than 1.0 (California, 1.15; Maryland, 1.25; North Carolina, 1.25; Texas, 1.19), while only 1 had an ARR less than 1.0 (Wisconsin, 0.79). However, after adjustment for race and ethnicity, no states had ARRs that varied significantly from 1.0.

CONCLUSION

Race and ethnicity, or other factors that covary with these, appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke. This finding suggests that the factors underlying the high rate of hemorrhagic strokes in dialysis patients are likely to be system-wide and that further investigations into regional variations in clinical practices are unlikely to identify large opportunities for preventive interventions for this disorder.

Factors predicting failure of AV "fistula first" policy in the elderly

An arteriovenous fistula (AVF) is the preferential hemodialysis (HD) access. The goal of this study was to identify factors associated with pre-dialysis AVF failure in an elderly HD population. We used United States Renal Data System + Medicare claims data to identify patients ≥ 67 years old who had an AVF as their initial vascular access placed pre-dialysis. Failure of the AVF to be used for initial HD, was used as the outcome. Logistic regression model was used to identify factors associated with AVF failure. The study cohort consisted of 20,360 subjects (76.2 ± 6.02 year old, 58.5% men). Forty-eight percent of patients initiated dialysis using an AVF, while 52% used a catheter or an AVG. The following variables found to be associated with AVF failure when an AVF was created at least 4 months pre-HD initiation: older age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00-1.02), female gender (OR 1.69; 95% CI 1.55-1.83), black race (OR 1.41; 95% CI 1.26-1.58), history of diabetes (OR 1.22; 95% CI 1.06-1.39), cardiac failure (OR 1.26; 95% CI 1.15-1.37), and shorter duration of pre-end-stage renal disease (ESRD) nephrology care (OR for a nephrology care of less than 6 months prior to ESRD of 1.22 compared with a pre-ESRD nephrology follow up of more than 12 months; 95% CI 1.07-1.38). OR for AVF failure for the entire cohort showed similar findings. In an elderly HD population, there is an association of older age, female gender, black race, diabetes, cardiac failure and shorter pre-ESRD nephrology care with predialysis AVF failure.

Clinical and economic value of performing dialysis vascular access procedures in a freestanding office-based center as compared with the hospital outpatient department among Medicare ESRD beneficiaries

Dialysis vascular access (DVA) care is being increasingly provided in freestanding office-based centers (FOC). Small-scale studies have suggested that DVA care in a FOC results in favorable patient outcomes and lower costs. To further evaluate this issue, data were drawn from incident and prevalent ESRD patients within a 4-year sample (2006-2009) of Medicare claims (USRDS) on cases who receive at least 80% of their DVA care in a FOC or a hospital outpatient department (HOPD). Using propensity score matching techniques, cases with a similar clinical and demographic profile from these two sites of service were matched. Medicare utilization, payments, and patient outcomes were compared across the matched cohorts (n = 27,613). Patients treated in the FOC had significantly better outcomes (p < 0.001), including fewer related or unrelated hospitalizations (3.8 vs. 4.4), vascular access-related infections (0.18 vs. 0.29), and septicemia-related hospitalizations (0.15 vs. 0.18). Mortality rate was lower (47.9% vs. 53.5%) as were PMPM payments ($4,982 vs. $5,566). This study shows that DVA management provided in a FOC has multiple advantages over that provided in a HOPD.

A Novel Electrospun Nano-fabric Graft Allows Early Cannulation Access and Reduces Exposure to Central Venous Catheters

Purpose

The use of tunneled central venous catheters (CVC) as vascular access for hemodialysis treatment is increasing worldwide. We present a novel polycarbonate urethane nano-fabric graft, produced by electrospinning technology, which has self-sealing features that avoid seroma formation and allow puncturing within 48 hours. The aim of this study was to assess its advantages in a setting where late referral is common.

Methods

A retrospective single center study assessed 24 implanted grafts in 24 patients with maximal follow-up of 18 months; patency rates, time to first cannulation and post-operative complications were assessed.

Results

Successful access was achieved in all 24 patients within 48 hours. In 50% of the patients cannulation was performed within 24 hours without increasing the complication rate. Twelve month primary and secondary patencies were 50% and 70.8%, respectively. Excluding early failures (within 30 days) because of surgical problems, 12 month primary and secondary patencies were 75% and 81.2% respectively. Complication and infection rates were 10.94 and 0.49/1000 dialysis procedures, respectively. No pseudoaneurysms or seromas were documented at 18 months.

Conclusions

Early cannulation was successful in all patients with good 12-month primary and secondary patency rates, compared to data reported by others on polytetrafluoroethylene (PTFE) grafts. The infection rate was substantially lower than in tunneled CVCs. Therefore, the AVflo graft may improve the clinical status of dialysis patients by decreasing the exposure to CVCs.

Accumulation of retained nonfunctional arteriovenous grafts correlates with severity of inflammation in asymptomatic ESRD patients

BACKGROUND

The contribution of multiple retained nonfunctional arteriovenous grafts (AVGs) to the burden of chronic inflammation in chronic hemodialysis patients has not been well studied. Here, we sought to evaluate the association between plasma levels of C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-alpha) and albumin and the number of retained nonfunctional AVGs.

METHODS

This cross-sectional study enrolled 91 prevalent patients undergoing in-center hemodialysis without evidence of infection or inflammation. A baseline blood sample was obtained at study enrollment. A general linear model (GLM) was used to compare levels of biomarkers of systemic inflammation across groups defined by the number of retained, nonfunctional AVGs.

RESULTS

A total of 43 patients had one or more retained thrombosed AVG and had significantly greater plasma log-CRP levels compared with patients without a previous AVG (P= 0.036), regardless of the current AV access type. Using a GLM, we found that for every additional retained thrombosed AVG, plasma log-CRP, log-IL-6 and TNF-alpha concentrations increased significantly by 0.30 mg/L (P= 0.011), 0.18 pg/mL (P= 0.046) and 0.72 pg/mL (P= 0.046), respectively, following adjustment.

CONCLUSIONS

Hence, the severity of inflammation increases with the number of retained nonfunctional AVG's, suggesting that AVG accumulation may contribute to the cardiovascular morbidity and mortality associated with chronic inflammation in asymptomatic end-stage renal disease (ESRD) patients. Further study is indicated to determine whether patients with one or more thrombosed, retained AVG may benefit from periodic screening with CRP monitoring to identify those patients who may benefit from AVG resection.

Impact of race on cumulative exposure to antihypertensive medications in dialysis

BACKGROUND

Racial minorities typically have less exposure than non-minorities to antihypertensive medications across an array of cardiovascular conditions in the general population. However, cumulative exposure has not been investigated in dialysis patients.

METHODS

In a longitudinal analysis of 38,381 hypertensive dialysis patients, prescription drug data from Medicaid was linked to Medicare data contained in United States Renal Data System core data, creating a national cohort of dialysis patients dually eligible for Medicare and Medicaid services. The proportion of days covered (PDC) was calculated to determine cumulative exposure to angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), β-blockers, and calcium-channel blockers (CCDs). The factors associated with use of these medications were modeled through weighted linear regression, with derivation of the adjusted odds ratios (AORs) for exposure.

RESULTS

Relative to non-Hispanic Caucasians, African-American, Hispanic, or Other race/ethnicity were significantly associated with less exposure to β-blockers (AOR 0.56-0.69, P < 0.001 in each case) and CCBs (AOR 0.84-0.85, P < 0.001 in each case); African-American race and Hispanic ethnicity had AORs of 0.78 and 0.73 for ACEIs and ARBs, respectively (P < 0.001 in both cases). Collectively, the odds of exposure to each class of medication for minorities was about three-quarters of that for Caucasians.

CONCLUSIONS

Given that dually Medicare-and-Medicaid-eligible dialysis patients have insurance coverage for prescription medications as well as regular contact with health care providers, differences by race in exposure to antihypertensive medications should with time be minimal among patients who are candidates for these drugs. The causes of differences by race in exposure to antihypertensive medications over the course of time should be further examined.

When should a patient receive an arteriovenous graft rather than a fistula?

There has been a dramatic increase in the placement and use of arteriovenous fistulas (AVF) in US patients with chronic kidney disease over the past few years, in accordance with strong recommendations by Fistula First Initiative and KDOQI guidelines. However, AVF nonmaturation remains a substantial obstacle to achieving functional AVFs in a subset of patients, despite the widespread use of preoperative vascular mapping to assist surgeons in planning access surgery, and the growing use of interventions to salvage nonmaturing AVFs. In the right patient, aggressive efforts result in a functioning AVF, which provides adequate dialysis with relatively few interventions required to maintain its long-term patency for dialysis. In the wrong patient, aggressive efforts to achieve a mature AVF may result in numerous failed surgical and percutaneous procedures and prolonged catheter dependence, with all its associated complications. Thus, strict recommendations to place an AVF in all dialysis patients might not benefit every patient, and may actually harm some patients. There are no randomized clinical trials to address which patients are more suitable for placement of an arteriovenous graft (AVG), rather than an AVF. However, there is a wealth of observational studies, which taken cumulatively, may assist clinicians in identifying those patients who should receive an AVG. In this article, we review the relevant published literature regarding this topic and provide suggestions for stratifying patients who should receive each type of vascular access.

Optimal hemodialysis vascular access in the elderly patient

The optimal vascular access for elderly patients remains a challenge due to the difficulty balancing the benefits and risks in a population with increased comorbidity and decreased survival. Age is commonly associated with failure to mature in fistula and decreased rates of primary and secondary patency in both fistula and grafts. In the elderly, at 1 and 2 years, primary patency rates range from 43% to 74% and from 29% to 67%, respectively. Secondary patency rates at 1 and 2 years range from 56% to 82% and 44% to 67%, respectively. Cumulative fistula survival is no better than grafts survival when primary failures are included. Several observational studies consistently demonstrate a lower adjusted mortality among those using a fistula compared with a catheter; however, catheter use in the elderly is increasing in most countries with the exception of Japan. Both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing the elderly patients with multiple chronic conditions and limited life expectancy or the value that patients place on achieving these outcomes. The framework for choice of vascular access presented in this article considers: (1) likelihood of disease progression before death, (2) patient life expectancy, (3) risks and benefits by vascular access type, and (4) patient preference. Future studies evaluating the timing and type of vascular access with careful assessments of complications, functionality, cost benefit, and patients' preference will provide relevant information to individualize and optimize care to improve morbidity, mortality, and quality of life in the elderly patient.

Primary patency time of basilic vein transposition versus prosthetic brachioaxillary access grafts in hemodialysis patients

PURPOSE

The aim of this study was to compare the primary patency time of basilic vein transposition and prosthetic brachioaxillary access grafts in hemodialysis patients.

METHODS

In this randomized clinical trial, 60 hemodialysis patients who met the inclusion/exclusion criteria were recruited and randomly assigned to two intervention groups; Basilic vein transpositions (BVT) or Arteriovenous access grafts (AVG). Clinical follow-up for patency of the created accesses in at least one year, was performed at two weeks, one, two, three months and then every three months after surgery. Finally, patency rates and access-related complications were compared in the two groups studied.

RESULTS

Thirty BVTs and thirty AVG were performed in each group studied. The groups were well matched for age, sex and comorbidity. After at least one year of follow-up, the access failure rate in the BVT and AVG groups was 23.3% and 30%, respectively. In addition, the mean primary patency time in the BVT and AVG groups was 244.13 ± 103.65 and 264.97 ± 149.28, respectively and there was no statistically significant difference between the two groups studied (P=.533). The common cause of access failure were thrombosis and infection but there were no statistically significant differences between the two groups (P>.05).

CONCLUSION

Our results show that AVG offer similar patency and complication rates to BVT. Thus, authors consider them as the preferred hemodialysis access when there are no suitable forearm veins to create arteriovenous fistulas.

Association of race with cumulative exposure to statins in dialysis

BACKGROUND

Patients on dialysis have high rates of cardiovascular disease and are frequently treated with HMG-CoA reductase inhibitors. Given that these patients have insurance coverage for medications as well as regular contact with health care providers, differences by race in exposure to statins over time should be minimal among patients who are candidates for the drug.

METHODS

We created a cohort of incident dialysis patients who were dually eligible for Medicare and Medicaid services. We determined the proportion of days covered (or PDC, a marker of cumulative medication exposure) by a statin prescription over a mean of 2.0 ± 1.4 years. Ordinary least squares regression was used to determine the factors associated with cumulative drug exposure.

RESULTS

Of the 18,727 patients who filled at least one prescription for a statin, mean PDC was 0.57 ± 0.32. The unadjusted PDC was higher for Caucasians (0.63 ± 0.31) than for African-Americans (0.51 ± 0.32), Hispanics (0.54 ± 0.31), and individuals of other race/ethnicity (0.58 ± 0.32). In multivariable modeling, Caucasian race was independently associated with greater exposure to statins. Relative to Caucasians, the adjusted odds ratios for the PDC for African-Americans was 0.47 (95% confidence interval, CI, 0.43-0.50), for Hispanics 0.52 (0.48-0.56) and for others, 0.72 (0.64-0.81).

CONCLUSIONS

Despite insurance coverage, regular contact with health care providers, and at least one prescription for a statin, there are large differences by race in statin exposure over time. The provider- and patient-associated factors related to this phenomenon should be further examined.

Tunelizador metálico rígido na confecção de fístulas arteriovenosas dos membros superiores

A qualidade de um acesso vascular condiciona os resultados clínicos dos pacientes tratados por hemodiálise. A criação de um túnel para a acomodação do conduto é uma etapa importante durante a realização do acesso. Desenvolveu-se um tunelizador metálico rígido, empregado na confecção de acessos vasculares. O aparato utilizado apresentou vantagens e segurança nas cirurgias de confecções de acessos venosos para hemodiálise dos membros superiores.

Hospitalization risks related to vascular access type among incident US hemodialysis patients

BACKGROUND

The excess morbidity and mortality related to catheter utilization at and immediately following dialysis initiation may simply be a proxy for poor prognosis. We examined hospitalization burden related to vascular access (VA) type among incident patients who received some predialysis care.

METHODS

We identified a random sample of incident US Dialysis Outcomes and Practice Patterns Study hemodialysis patients (1996-2004) who reported predialysis nephrologist care. VA utilization was assessed at baseline and throughout the first 6 months on dialysis. Poisson regression was used to estimate the risk of all-cause and cause-specific hospitalizations during the first 6 months.

RESULTS

Among 2635 incident patients, 60% were dialyzing with a catheter, 22% with a graft and 18% with a fistula at baseline. Compared to fistulae, baseline catheter use was associated with an increased risk of all-cause hospitalization [adjusted relative risk (RR) = 1.30, 95% confidence interval (CI): 1.09-1.54] and graft use was not (RR = 1.07, 95% CI: 0.89-1.28). Allowing for VA changes over time, the risk of catheter versus fistula use was more pronounced (RR = 1.72, 95% CI: 1.42-2.08) and increased slightly for graft use (RR = 1.15, 95% CI: 0.94-1.41). Baseline catheter use was most strongly related to infection-related (RR = 1.47, 95% CI: 0.92-2.36) and VA-related hospitalizations (RR = 1.49, 95% CI: 1.06-2.11). These effects were further strengthened when VA use was allowed to vary over time (RR = 2.31, 95% CI: 1.48-3.61 and RR = 3.10, 95% CI: 1.95-4.91, respectively). A similar pattern was noted for VA-related hospitalizations with graft use. Discussion. Among potentially healthier incident patients, hospitalization risk, particularly infection and VA-related, was highest for patients dialyzing with a catheter at initiation and throughout follow-up, providing further support to clinical practice recommendations to minimize catheter placement.

Medicare reimbursement policies and hemodialysis vascular access outcomes: a need for change

In March 2010, the Center for Medicare and Medicaid Services (CMS) convened several clinical technical expert panels (C-TEP) to provide recommendations for improving various aspects of hemodialysis management. One of the C-TEPs was tasked with recommending measures to decrease vascular access-related infections. The members of this C-TEP, who are the authors of this manuscript, concluded unanimously that the single most important measure would be to remove financial and regulatory barriers to timely placement and revision of hemodialysis fistulas and the concurrent avoidance of catheter use. The following position paper outlines the financial barriers to improved vascular access outcomes and our proposals for a future CMS demonstration project.

Haemodialysis catheters increase mortality as compared to arteriovenous accesses especially in elderly patients

BACKGROUND

Catheter use has been associated with an increased mortality risk in haemodialysis patients. However, differences in the all-cause and cause-specific mortality risk between catheter use and arteriovenous access use in young and elderly haemodialysis patients have not yet been investigated.

METHODS

In this prospective cohort study of 1109 incident haemodialysis patients from 38 centres in the Netherlands, hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated for 2-year all-cause, infection-related and cardiovascular mortality in patients with a catheter as compared to patients with an arteriovenous access stratified for age (< 65 years and ≥ 65 years).

RESULTS

Of the 1109 patients, 919 had an arteriovenous access and 190 had a catheter. The mortality rate was 76 per 1000 person-years in young patients with an arteriovenous access, 129 per 1000 person-years in young patients with a catheter, 222 per 1000 person-years in elderly patients with an arteriovenous access and 427 per 1000 person-years in elderly patients with a catheter. The adjusted HR was 3.15 (95% CI: 2.09-4.75) for elderly patients with a catheter as compared to young patients with an arteriovenous access. The adjusted HRs in elderly patients with a catheter as compared to elderly patients with an arteriovenous access were 1.54 (95% CI: 1.13-2.12) for all-cause mortality, 1.60 (95%: CI 0.62-4.19) for infection-related mortality and 1.67 (95% CI: 1.04-2.68) for cardiovascular mortality.

CONCLUSIONS

Especially, elderly haemodialysis patients with a catheter have an increased all-cause, infection-related and cardiovascular mortality risk as compared to patients with an arteriovenous access.

Infections in hemodialysis: a concise review - Part 1: bacteremia and respiratory infections

Hemodialysis (HD) patients are particularly predisposed to infections. It seems that the HD procedure per se as well as disturbances in both innate and adaptive immunity significantly contribute to this susceptibility. Infections are the major cause of morbidity and the second cause of death following cardiovascular events in HD patients. Episodes of bacteremia and pneumonia account for the majority of severe infections in this population. In addition to these bacterial infections another common problem in HD units is the blood transmitted viral infections, particularly infections caused by hepatitis B virus, hepatitis C virus and Human immunodeficiency virus. A number of safety concerns exist for limiting the spread of these viral infections among HD patients and the staff of the unit. The aim of the present review is to present in a concise albeit practical form the difficult aspect of infections in HD. For practical reasons the review is separated in two parts. The present first part covers bacteremia and respiratory infections, while the second part will cover blood transmitted viral infections.

Racial and gender differences in arteriovenous fistula use among incident hemodialysis patients

BACKGROUND

Arteriovenous fistula (AVF) use is reported to differ among racial and gender groups. We sought to identify risk factors associated with incident AVF and whether racial and gender differences in AVF use persist after controlling for these factors.

METHODS

We evaluated 28,712 incident adult hemodialysis patients (age ≥ 18) from five ESRD networks starting dialysis between June 1, 2005 and May 31, 2006. Data were obtained from the Center for Medicaid and Medicare Services 2728 form.

RESULTS

Incident AVF use was reported for 11% of black and 12% of white patients [OR = 0.89 (95% CI: 0.83, 0.96)], and for 9% of females and 13% of males [OR = 0.66 (0.62-0.71)]. After adjusting for facility clustering, blacks were as likely as whites to use an AVF [OR = 1.00 (0.92-1.09)], while gender differences persisted [OR = 0.64 (0.59-0.69)]. Compared to patients with no renal care prior to dialysis initiation, incident AVF use was 16-fold greater among those with ≥ 12 months of nephrology care [OR = 15.99 (13.25-19.29)], 9-fold greater among those with 6-12 months of care [OR = 9.00 (7.45-10.88)] and 7-fold greater among those with at least 6 months of care [OR = 7.13 (5.73-8.88)].

CONCLUSION

Racial, but not gender, differences in incident AVF use were eliminated after accounting for clustering within facilities.

The elderly patients on hemodialysis

Nephrologists care for an increasing number of elderly patients on hemodialysis. As such, an understanding of the overlap among complications of hemodialysis and geriatric syndromes is crucial. This article reviews hemodialysis management issues including vascular access, hypertension, anemia and bone and mineral disorders with an attention towards the distinct medical needs of the elderly. Key concepts of geriatrics frailty, dementia and palliative care are also discussed, as nephrologists frequently participate in decision-making directed toward balancing longevity, functional status and the burden of therapy.

Vascular access for dialysis: recent lessons and new insights

PURPOSE OF REVIEW

Vascular access complications are a major cause of excessive morbidity and mortality in the dialysis population. This review will focus on recent changes in vascular access practices and access management directly affecting patient outcomes.

RECENT FINDINGS

The proportion of patients dialyzing via arteriovenous fistulas continues to increase as a result of national initiatives. Maturation failure is now the main obstacle to successful use of fistulas. Arteriovenous grafts remain an important vascular access option for dialysis, and interventions to prevent progression of stenosis are being explored. Central venous catheter prevalence has increased and new interventions to address catheter-related complications such as thrombosis and infection are promising.

SUMMARY

Advances in understanding the factors related to fistula maturation failure will have a major beneficial effect on vascular access outcomes. New approaches to prevent graft and catheter-related complications should complement advances on fistula management. Optimal patient selection for specific access modalities and institution of timely access interventions tested in rigorous clinical trials should be the next step to improve access management.

Conversion of vascular access type among incident hemodialysis patients: description and association with mortality

BACKGROUND

Limited data exist describing vascular access conversions during the first year on dialysis therapy or the effect of converting to and from a catheter on subsequent mortality risk.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

We studied a random sample of incident US hemodialysis patients (initiated long-term dialysis < 30 days before study entry) in the Dialysis Outcomes and Practice Patterns Study (DOPPS; 1996-2004).

PREDICTORS

At dialysis therapy initiation, we assessed vascular access type in use (arteriovenous fistula [AVF], arteriovenous graft [AVG], or catheter) and other patient characteristics. We characterized changes in vascular access type (conversions) by using regularly collected functional status information.

OUTCOME & MEASUREMENTS

We assessed time to all-cause mortality. We first described conversions, then used time-dependent Cox regression to estimate mortality hazard ratios (HRs) for conversions from a catheter to a permanent vascular access (versus no conversion) and conversions from a permanent vascular access to a catheter (versus no conversion).

RESULTS

The study included 4,532 patients; 69.2% were dialyzing with a catheter; 17.6%, with an AVG; and 13.1%, with an AVF. In patients initiating therapy with an AVF or AVG, 22% experienced a conversion (failure), and median times to first failure were 62 and 84 days, respectively. In catheter patients, 59% converted to an AVF/AVG (predominantly AVG [57%]); median times to first conversion were 92 and 66 days, respectively. Conversion to a permanent access was associated with an adjusted mortality HR of 0.69 (95% confidence interval, 0.55 to 0.85). The effect was similar for conversion to an AVF or AVG, and these persisted across demographic groups and facilities with different conversion practices. Conversion from a permanent vascular access to a catheter was associated with an adjusted mortality HR of 1.81 (95% confidence interval, 1.22 to 2.68).

LIMITATIONS

Potential for residual confounding because of unmeasured factors influencing decision to convert.

CONCLUSION

Vascular access conversions are common in incident patients. Continued efforts to increase early nephrologist referral and permanent vascular access placement may help decrease mortality risk in incident dialysis patients.

Catheter-related mortality among ESRD patients

Hemodialysis access-related complications remain one of the most important sources of morbidity and cost among persons with end-stage renal disease, with total annual costs exceeding $1 billion annually. In this context, the creation and maintenance of an effective hemodialysis vascular access is essential for safe and adequate hemodialysis therapy. Multiple reports have documented the type of vascular access used for dialysis and associated risk of infection and mortality. Undoubtedly, the central venous catheter (CVC) is associated with the greatest risk of infection-related and all-cause mortality compared with the autogenous arteriovenous fistula (AVF) or synthetic graft (AVG). The AVF has the lowest risk of infection, longer patency rates, greater quality of life, and lower all-cause mortality compared with the AVG or CVC. It is for these reasons that the National Kidney Foundation's Kidney Disease Outcome Quality Initiative Clinical Practice Guidelines for Vascular Access recommend the early placement and use of the AVF among at least 50% of incident hemodialysis patients. This report presents catheter-related mortality and calls for heightened awareness of catheter-related complications.

Arteriovenous fistula use is associated with lower cardiovascular mortality compared with catheter use among ESRD patients

The arteriovenous fistula (AVF) is the recommended form of dialysis vascular access, however, limited studies suggest that AVF creation may result in increased cardiovascular stress and remodeling. To explore the contribution of vascular access type to cardiovascular-related (CV) mortality, we analyzed USRDS Clinical Performance Measures data comprising 4854 patients that initiated dialysis between October 1, 1999-December 31, 2004. CV mortality included death from acute myocardial infarction, atherosclerotic heart disease, cardiomyopathy, arrhythmia, cardiac arrest or stroke. Risk of cardiovascular mortality during a 4-year observation was analyzed by Cox-regression methods with adjustments for demographic and co-morbid conditions. AVF use was strongly associated with lower all-cause and CV mortality. After adjustment for covariates, AVF use 90 days after dialysis initiation remained significantly associated with lower cardiovascular mortality [hazard ratio (HR) 0.69, p = 0.0004] compared with catheter use. These findings suggest that vascular access type influences cause-specific mortality beyond that of infection, and support existing guidelines recommending the use of an AVF early in the course of chronic end-stage renal disease therapy.