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Malik MJ, Nabi RJ. Assessing the Inflow Segment of a Hemodialysis Access: The Fogarty Balloon Occlusion Technique. Cureus 2023; 15:e41534. [PMID: 37551204 PMCID: PMC10404460 DOI: 10.7759/cureus.41534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/09/2023] Open
Abstract
Dialysis access maintenance often requires a fistulogram or shuntogram of arteriovenous access. Assessment of the arterial inflow segment and arterial anastomosis is often a critical portion of the procedure. Retrograde occlusive angiography (ROA) is often used to properly assess the inflow. Manual compression using finger compression or a hemostat is often described in the literature. The Fogarty balloon occlusion technique using a 4-Fr Fogarty catheter balloon (Henry Shein) is a simple and cost-effective method that preserves image quality and decreases radiation exposure in retrograde occlusive angiography.
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Affiliation(s)
- Mona J Malik
- Internal Medicine, University of California, Riverside, Riverside, USA
| | - Rema J Nabi
- Vascular Surgery, University of Houston, Houston, USA
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2
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Flythe JE, Narendra JH, Yule C, Manivannan S, Murphy S, Lee SYD, Strigo TS, Peskoe S, Pendergast JF, Boulware LE, Green JA. Targeting Patient and Health System Barriers To Improve Rates of Hemodialysis Initiation with an Arteriovenous Access. KIDNEY360 2021; 2:708-720. [PMID: 35373037 PMCID: PMC8791324 DOI: 10.34067/kid.0007812020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/24/2021] [Indexed: 02/04/2023]
Abstract
Background Guidelines recommend pre-emptive creation of arteriovenous (AV) access. However, <20% of US patients initiate hemodialysis (HD) with a functional AV access. We implemented a quality improvement (QI) program to improve pre-HD vascular access care. Methods After conducting qualitative research with key informants, we implemented a 7-month vascular access support QI program at Geisinger Health. The program targeted patient and health system barriers to AV access through education, needs assessment, peer support, care navigation, and electronic supports. We performed pre-, intra-, and postprogram stakeholder interviews to identify program barriers and facilitators and to assess acceptability. In a research substudy, we compared pre- and postprogram self-efficacy, knowledge, and confidence navigating vascular access care. Results There were 37 patient and 32 clinician/personnel participants. Of the 37 patients, 34 (92%) completed vascular access-specific education, 33 (89%) underwent needs assessment, eight (22%) engaged with peer mentors, 21 (57%) had vein mapping, 18 (49%) had an initial surgical appointment, 15 (40%) underwent AV access surgery, and six (16%) started HD during the 7-month program. Qualitative findings demonstrated program acceptability to participants and suggested that education provision and emotional barrier identification were important to engaging patients in vascular access care. Research findings showed pre- to postprogram improvements in patient self-efficacy (28.1-30.8, P=0.05) and knowledge (4.9-6.9, P=0.004), and trends toward improvements in confidence among patients (8.0-8.7, P=0.2) and providers (7.5-7.8, P=0.1). Conclusions Our intervention targeting patient and health system barriers improved patient vascular access knowledge and self-efficacy. Clinical Trial registry name and registration number Breaking Down Care Process and Patient-level Barriers to Arteriovenous Access Creation Prior to Hemodialysis Initiation, NCT04032613.
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Affiliation(s)
- Jennifer E. Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Julia H. Narendra
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
| | - Christina Yule
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
| | - Surya Manivannan
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
| | - Shannon Murphy
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
| | - Shoou-Yih D. Lee
- Department of Health Administration, College of Health Professions, Virginia Commonwealth University, Richmond, Virginia
| | - Tara S. Strigo
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Jane F. Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - L. Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jamie A. Green
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania,Department of Nephrology, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
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3
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Packer D, Kaufman JS. Catheter First: The Reality of Incident Hemodialysis Patients in the United States. Kidney Med 2020; 2:242-244. [PMID: 32734964 PMCID: PMC7380429 DOI: 10.1016/j.xkme.2020.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- David Packer
- Division of Nephrology, New York University School of Medicine, New York, NY
| | - James S. Kaufman
- Division of Nephrology, New York University School of Medicine, New York, NY
- VA New York Harbor Healthcare System, New York, NY
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Tang TT, Levin ML, Ahya SN, Boobes K, Hasan MH. Initiation of maintenance hemodialysis through central venous catheters: study of patients' perceptions based on a structured questionnaire. BMC Nephrol 2019; 20:270. [PMID: 31315677 PMCID: PMC6637564 DOI: 10.1186/s12882-019-1422-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 06/17/2019] [Indexed: 02/07/2023] Open
Abstract
Background Despite well-publicized suggestions to utilize arteriovenous fistulae and grafts to initiate hemodialysis, too many patients in the United States start dialysis via central venous catheters despite their well-known association with increased morbidity, mortality, and cost. Methods To determine the reasons for this high rate of catheter use, and, ultimately, ways to reduce it, we developed a questionnaire designed to determine where in the process of patient care the process to fistula or graft placement was not completed, thus requiring the use of central venous catheters. The questionnaire was reviewed by several nephrologists not involved with the study. We administered the questionnaire to 52 consecutive hospitalized patients who started maintenance dialysis with catheters at a University-affiliated Hospital and referral center. The questionnaire asked each patient to provide details pertaining to pre-dialysis care, referrals, and follow-through on recommended referrals. If the patient did not see the physician to whom he/she was referred, we asked the reason(s) for such failure. Results Patient responses showed that there were two major lapses in the transition from diagnosis of advanced kidney disease to construction of appropriate dialysis access: failure by the patients to see a nephrologist and/or an access surgeon, and failure by physicians to refer patients to an access surgeon. Twenty percent of the patients failed to follow up with either a nephrologist or a surgeon. Only 38% (15/40) of those seen by a nephrologist had been referred to a surgeon. Conclusions The quality of care was impaired by lack of referral to surgeons by nephrologists and by lack of follow-through by patients. Areas for improvement include improved communications between physicians and patients and more careful follow-up by both physicians and patients. Several methods of providing better patient care and communication between patients and nephrologists are recommended. Electronic supplementary material The online version of this article (10.1186/s12882-019-1422-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tanya T Tang
- Division of Nephrology/Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, 60611, USA.,Present address: Foothills Nephrology, 126 Dillon Drive, Spartanburg, SC, 29307, USA
| | - Murray L Levin
- Division of Nephrology/Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, 60611, USA. .,, Highland Park, USA.
| | - Shubhada N Ahya
- Division of Nephrology/Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, 60611, USA
| | - Khaled Boobes
- Division of Nephrology/Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, 60611, USA.,Present address: Nephrology Division OSU, 95 W 12th Ave#7, Columbus, OH, 43210, USA
| | - Muhammad H Hasan
- United Elite Hospitalists, 12632 S Harlem Ave, Palos Heights, IL, 60463, USA
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Lin E, Mell MW, Winkelmayer WC, Erickson KF. Health Insurance in the First 3 Months of Hemodialysis and Early Vascular Access. Clin J Am Soc Nephrol 2018; 13:1866-1875. [PMID: 30385594 PMCID: PMC6302322 DOI: 10.2215/cjn.06660518] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/29/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients without Medicare who develop ESKD in the United States become Medicare eligible by their fourth dialysis month. Patients without insurance may experience delays in obtaining arteriovenous fistulas or grafts before obtaining Medicare coverage. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this retrospective cohort study, we used a national registry to compare uninsured patients starting in-center hemodialysis with a central venous catheter between 2010 and 2013 with similar patients with Medicare or Medicaid. We evaluated whether insurance status at dialysis start influenced the likelihoods of switching to dialysis through an arteriovenous fistula or graft and hospitalizations involving a vascular access infection. We used multivariable logistic and Cox regression models and transformed odds ratios to relative risks using marginal effects. RESULTS Patients with Medicare or Medicaid were more likely to switch to an arteriovenous fistula or graft by their fourth dialysis month versus uninsured patients (Medicare hazard ratio, 1.63; 95% confidence interval, 1.14 to 2.43; Medicaid hazard ratio, 1.23; 95% confidence interval, 1.12 to 1.38). There were no differences in rates of switching to arteriovenous fistulas or grafts after all patients obtained Medicare in their fourth dialysis month (Medicare hazard ratio, 1.17; 95% confidence interval, 0.97 to 1.42; Medicaid hazard ratio, 1.01; 95% confidence interval, 0.96 to 1.06). Patients with Medicare at dialysis start had fewer hospitalizations involving vascular access infection in dialysis months 4-12 (hazard ratio, 0.60; 95% confidence interval, 0.37 to 0.97). CONCLUSIONS Insurance-related disparities in the use of arteriovenous fistulas and grafts persist through the fourth month of dialysis, may not fully correct after all patients obtain Medicare coverage, and may lead to more frequent vascular access infections.
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Affiliation(s)
- Eugene Lin
- Division of Nephrology, Department of Medicine and
- Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Division of Nephrology, Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Matthew W. Mell
- Division of Vascular Surgery, Department of Surgery, University of California, Davis, Sacramento, California
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; and
- Baker Institute for Public Policy, Rice University, Houston, Texas
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6
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Woodside KJ, Bell S, Mukhopadhyay P, Repeck KJ, Robinson IT, Eckard AR, Dasmunshi S, Plattner BW, Pearson J, Schaubel DE, Pisoni RL, Saran R. Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study. Am J Kidney Dis 2018; 71:793-801. [PMID: 29429750 PMCID: PMC6551206 DOI: 10.1053/j.ajkd.2017.11.020] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/22/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States. STUDY DESIGN Nonconcurrent observational cohort study. SETTING & PARTICIPANTS Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System. PREDICTORS Demographics, geographic location, dialysis vintage, comorbid conditions. OUTCOMES Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data. MEASUREMENTS AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of 2014. RESULTS In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation. LIMITATIONS This study relies on administrative data, with monthly recording of access use. CONCLUSIONS We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.
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Affiliation(s)
- Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Sarah Bell
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Purna Mukhopadhyay
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Kaitlyn J Repeck
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Ian T Robinson
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Ashley R Eckard
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Sudipta Dasmunshi
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Brett W Plattner
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jeffrey Pearson
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Ronald L Pisoni
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI.
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7
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Patel PR, Brinsley-Rainisch K. The Making Dialysis Safer for Patients Coalition: A New Partnership to Prevent Hemodialysis-Related Infections. Clin J Am Soc Nephrol 2018; 13:175-181. [PMID: 28794000 PMCID: PMC5753304 DOI: 10.2215/cjn.02730317] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The Making Dialysis Safer for Patients Coalition is a partnership of organizations and individual stakeholders that share the common goal to prevent bloodstream infections among patients receiving hemodialysis. Led by the Centers for Disease Control and Prevention (CDC), in collaboration with the CDC Foundation, this public-private partnership strives to improve adherence to evidence-based recommendations, share information and experiences, and engage patients in infection prevention efforts.
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Affiliation(s)
- Priti R Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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8
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Rich NC, Vartanian SM, Sharief S, Freitas DJ, Tuot DS. A mixed-methods investigation of incident Hemodialysis access in a safety-net population. BMC Nephrol 2017; 18:279. [PMID: 28865432 PMCID: PMC5581413 DOI: 10.1186/s12882-017-0700-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Despite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally. Methods We performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access. Results Subjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0–6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02–0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23–12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16–0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17–1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery. Conclusions The rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients’ emotional and learning needs may decrease delays in fistula placement.
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Affiliation(s)
- Nicole C Rich
- Department of Surgery, General Surgery Residency Program, U.C. San Francisco, 513 Parnassus Ave., S321, San Francisco, CA, 94143-0470, USA.
| | - Shant M Vartanian
- Department of Surgery, Division of Vascular & Endovascular Surgery, U.C. San Francisco, 400 Parnassus Ave., Suite A-501, San Francisco, CA, 94143, USA
| | - Shimi Sharief
- Department of Medicine, Division of Nephrology, U.C. San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Daniel J Freitas
- School of Medicine, U.C. San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Delphine S Tuot
- Department of Medicine, Division of Nephrology, U.C. San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
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9
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Al-Balas A, Lee T, Young CJ, Kepes JA, Barker-Finkel J, Allon M. The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter. J Am Soc Nephrol 2017; 28:3679-3687. [PMID: 28710090 DOI: 10.1681/asn.2016060707] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/08/2017] [Indexed: 11/03/2022] Open
Abstract
Patients in the United States frequently initiate hemodialysis with a central venous catheter (CVC) and subsequently undergo placement of a new arteriovenous fistula (AVF) or arteriovenous graft (AVG). Little is known about the clinical and economic effects of initial vascular access choice. We identified 479 patients starting hemodialysis with a CVC at a large medical center (during 2004-2012) who subsequently had an AVF (n=295) or AVG (n=105) placed or no arteriovenous access (CVC group, n=71). Compared with patients receiving an AVG, those receiving an AVF had more frequent surgical access procedures per year (1.01 [95% confidence interval, 0.95 to 1.08] versus 0.62 [95% confidence interval, 0.55 to 0.70]; P<0.001) but a similar frequency of percutaneous access procedures per year. Patients receiving an AVF had a higher median annual cost (interquartile range) of surgical access procedures than those receiving an AVG ($4857 [$2523-$8835] versus $2819 [$1411-$4274]; P<0.001), whereas the annual cost of percutaneous access procedures was similar in both groups. The AVF group had a higher median overall annual access-related cost than the AVG group ($10,642 [$5406-$19,878] versus $6810 [$3718-$13,651]; P=0.001) after controlling for patient age, sex, race, and diabetes. The CVC group had the highest median annual overall access-related cost ($28,709 [$11,793-$66,917]; P<0.001), largely attributable to the high frequency of hospitalizations due to catheter-related bacteremia. In conclusion, among patients initiating hemodialysis with a CVC, the annual cost of access-related procedures and complications is higher in patients who initially receive an AVF versus an AVG.
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Affiliation(s)
| | - Timmy Lee
- Divisions of Nephrology and.,Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama
| | - Carlton J Young
- Transplant Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and
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10
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Ravani P, Quinn R, Oliver M, Robinson B, Pisoni R, Pannu N, MacRae J, Manns B, Hemmelgarn B, James M, Tonelli M, Gillespie B. Examining the Association between Hemodialysis Access Type and Mortality: The Role of Access Complications. Clin J Am Soc Nephrol 2017; 12:955-964. [PMID: 28522650 PMCID: PMC5460718 DOI: 10.2215/cjn.12181116] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/24/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES People receiving hemodialysis to treat kidney failure need a vascular access (a fistula, a graft, or a central venous catheter) to connect to the blood purification machine. Higher rates of access complications are considered the mechanism responsible for the excess mortality observed among catheter or graft users versus fistula users. We tested this hypothesis using mediation analysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied incident patients who started hemodialysis therapy from North America, Europe, and Australasia (the Dialysis Outcomes and Practice Patterns Study; 1996-2011). We evaluated the association between access type and time to noninfectious (e.g., thrombosis) and infectious complications of the access (mediator model) and the relationship between access type and time-dependent access complications with 6-month mortality from the creation of the first permanent access (outcome model). In mediation analysis, we formally tested whether access complications explain the association between access type and mortality. RESULTS Of the 6119 adults that we studied (mean age =64 [SD=15] years old; 58% men; 47% patients with diabetes), 50% had a permanent catheter for vascular access, 37% had a fistula, and 13% had a graft. During the 6-month study follow-up, 2084 participants (34%) developed a noninfectious complication of the access, 542 (8.9%) developed an infectious complication, and 526 (8.6%) died. Access type predicted the occurrence of access complications; both access type and complications predicted mortality. The associations between access type and mortality were nearly identical in models excluding and including access complications (hazard ratio, 2.00; 95% confidence interval, 1.55 to 2.58 versus hazard ratio, 2.01; 95% confidence interval, 1.56 to 2.59 for catheter versus fistula, respectively). In mediation analysis, higher mortality with catheters or grafts versus fistulas was not the result of increased rates of access complications. CONCLUSIONS Hemodialysis access complications do not seem to explain the association between access type and mortality. Clinical trials are needed to clarify whether these associations are causal or reflect confounding by underlying disease severity.
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Affiliation(s)
- Pietro Ravani
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Quinn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Neesh Pannu
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada; and
| | - Jennifer MacRae
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden Manns
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew James
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
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11
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Robinson BM, Akizawa T, Jager KJ, Kerr PG, Saran R, Pisoni RL. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices. Lancet 2016; 388:294-306. [PMID: 27226132 PMCID: PMC6563337 DOI: 10.1016/s0140-6736(16)30448-2] [Citation(s) in RCA: 254] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More than 2 million people worldwide are being treated for end-stage kidney disease (ESKD). This Series paper provides an overview of incidence, modality use (in-centre haemodialysis, home dialysis, or transplantation), and mortality for patients with ESKD based on national registry data. We also present data from an international cohort study to highlight differences in haemodialysis practices that affect survival and the experience of patients who rely on this therapy, which is both life-sustaining and profoundly disruptive to their quality of life. Data illustrate disparities in access to renal replacement therapy of any kind and in the use of transplantation or home dialysis, both of which are widely considered preferable to in-centre haemodialysis for many patients with ESKD in settings where infrastructure permits. For most patients with ESKD worldwide who are treated with in-centre haemodialysis, overall survival is poor, but longer in some Asian countries than elsewhere in the world, and longer in Europe than in the USA, although this gap has reduced. Commendable haemodialysis practice includes exceptionally high use of surgical vascular access in Japan and in some European countries, and the use of longer or more frequent dialysis sessions in some countries, allowing for more effective volume management. Mortality is especially high soon after ESKD onset, and improved preparation for ESKD is needed including alignment of decision making with the wishes of patients and families.
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Affiliation(s)
- Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA; Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA.
| | - Tadao Akizawa
- Showa University School of Medicine, Shinagawa, Tokyo, Japan
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam-Zuidoost, Netherlands
| | - Peter G Kerr
- Monash Medical Centre and Monash University Clayton, Clayton, VIC, Australia
| | - Rajiv Saran
- Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA
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Kalloo S, Blake PG, Wish J. A Patient-Centered Approach to Hemodialysis Vascular Access in the Era of Fistula First. Semin Dial 2016; 29:148-57. [PMID: 26756825 DOI: 10.1111/sdi.12465] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The primary vascular access options for the hemodialysis population are arteriovenous fistulas (AVF), arteriovenous grafts, and cuffed central venous catheters (CVC). AVFs are associated with the most favorable outcomes with respect to complications, interventions required to maintain functionality and patency, and overall cost. These population-based outcomes, in conjunction with the efforts of the Fistula First Breakthrough Initiative, have propelled the prevalence of AVFs in the US hemodialysis population. While this endeavor remains steadfast in assuring the continued dominance of this policy for AVF preference, it fails to take into account a subset of the dialysis population who will fail to see the benefits of an AVF. This subset of patients may include the elderly, those with poor vasculature anatomy, those with slowly progressive CKD who are more likely to die than progress to ESRD, and those with an overall poor long-term prognosis and shortened life expectancy. Thus, in an effort to avoid numerous unnecessary surgical and interventional procedures with minimal to no gains in clinical outcomes, an individualized patient approach must be adopted. The Centers for Medicare and Medicaid Services-instituted quality incentive program is designed to reward high AVF prevalence while also penalizing high CVC prevalence. The current model is devoid of case-based adjustment, thus penalties are disbursed to dialysis providers in accordance with a "one-size-fits-all" fistula only approach. The most suitable access for a patient remains the one that takes into account the characteristics unique to the individual patient with a primary focus on patient comfort, satisfaction, quality of life, and clinical outcomes.
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Affiliation(s)
- Sean Kalloo
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York
| | - Peter G Blake
- Division of Nephrology, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Jay Wish
- Division of Nephrology, Department of Medicine, Indiana University Health, Indianapolis, Indiana
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Lacson E. Decreasing Exposure to Hemodialysis Catheters in ESRD--More Work to Be Done. Am J Kidney Dis 2015; 65:820-2. [PMID: 26003610 DOI: 10.1053/j.ajkd.2015.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 03/10/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Eduardo Lacson
- Fresenius Medical Care North America, Waltham, Massachusetts.
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Pisoni RL, Zepel L, Port FK, Robinson BM. Trends in US Vascular Access Use, Patient Preferences, and Related Practices: An Update From the US DOPPS Practice Monitor With International Comparisons. Am J Kidney Dis 2015; 65:905-15. [PMID: 25662834 DOI: 10.1053/j.ajkd.2014.12.014] [Citation(s) in RCA: 207] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 12/11/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Since the bundled end-stage renal disease prospective payment system began in 2011 in the United States, some hemodialysis practices have changed substantially, raising the question of whether vascular access practice also has changed. We describe monthly US vascular access use from August 2010 to August 2013 with international comparisons, and other aspects of US vascular access practice. STUDY DESIGN Prospective observational cohort study of vascular access. SETTING & PARTICIPANTS Maintenance hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) in the United States (N=3,442; US patients) and 19 other nations (N=8,478). PREDICTORS Country, patient demographics, time period. OUTCOMES Vascular access use, pre-end-stage renal disease access timing of first nephrologist care and arteriovenous access placement, patient self-reported vascular access preferences (United States only), treatment practices as stated by medical directors. RESULTS In the United States from August 2010 to August 2013, arteriovenous fistula (AVF) use increased from 63% to 68%, while catheter use declined from 19% to 15%. Although AVF use did not differ greatly across age groups, arteriovenous graft use was 2-fold higher among black (26%) versus nonblack US patients (13%) in 2013. Across 20 countries in 2013, AVF use ranged from 49% to 92%, whereas catheter use ranged from 1% to 45%. Patient-reported vascular access preferences differed by sex and race, with 16% to 20% of patients feeling uninformed regarding benefits/risks of different vascular access types. Among new (incident) US hemodialysis patients, AVF use remains low, with ∼70% initiating hemodialysis therapy with a catheter (60% starting with catheter when having ≥4 months of predialysis nephrology care). In the United States, longer typical times to first AVF cannulation were reported. LIMITATIONS Noncompletion of surveys may affect the generalizability of findings to the wider hemodialysis population. CONCLUSIONS AVF use has increased, with catheter use decreasing among prevalent US hemodialysis patients since the introduction of the prospective payment system. However, AVF use at dialysis therapy initiation remains low, suggesting that reforms affecting predialysis care may be necessary to incentivize improvements in fistula rates at dialysis therapy initiation as achieved for prevalent hemodialysis patients.
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Affiliation(s)
| | - Lindsay Zepel
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Boyce JM. Prevention of Central Line–Associated Bloodstream Infections in Hemodialysis Patients. Infect Control Hosp Epidemiol 2015; 33:936-44. [DOI: 10.1086/667369] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
An increasing proportion of central line-associated bloodstream infections (CLABSIs) are seen in outpatient settings. Many of such infections are due to hemodialysis catheters (HD-CLABSIs). Such infections are associated with substantial morbidity, mortality, and excess healthcare costs. Patients who receive dialysis through a catheter are 2–3 times more likely to be hospitalized for infection and to die of septic complications than dialysis patients with grafts or fistulas. Prevention measures include minimizing the use of hemodialysis catheters, use of CLABSI prevention bundles for line insertion and maintenance, and application of antimicrobial ointment to the catheter exit site. Instillation into dialysis catheters of antimicrobial solutions that remain in the catheter lumen between dialyses (antimicrobial lock solutions) has been studied, but it is not yet standard practice in some dialysis units. At least 34 studies have evaluated the impact of antimicrobial lock solutions on HD-CLABSI rates. Thirty-two (94%) of the 34 studies demonstrated reductions in HD-CLABSI rates among patients treated with antimicrobial lock solutions. Recent multicenter randomized controlled trials demonstrated that the use of such solutions resulted in significantly lower HD-CLABSI rates, even though such rates were low in control groups. The available evidence supports more routine use of antimicrobial lock solutions as an HD-CLABSI prevention measure in hemodialysis units.
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16
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Drew DA, Lok CE, Cohen JT, Wagner M, Tangri N, Weiner DE. Vascular access choice in incident hemodialysis patients: a decision analysis. J Am Soc Nephrol 2014; 26:183-91. [PMID: 25063436 DOI: 10.1681/asn.2013111236] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Hemodialysis vascular access recommendations promote arteriovenous (AV) fistulas first; however, it may not be the best approach for all hemodialysis patients, because likelihood of successful fistula placement, procedure-related and subsequent costs, and patient survival modify the optimal access choice. We performed a decision analysis evaluating AV fistula, AV graft, and central venous catheter (CVC) strategies for patients initiating hemodialysis with a CVC, a scenario occurring in over 70% of United States dialysis patients. A decision tree model was constructed to reflect progression from hemodialysis initiation. Patients were classified into one of three vascular access choices: maintain CVC, attempt fistula, or attempt graft. We explicitly modeled probabilities of primary and secondary patency for each access type, with success modified by age, sex, and diabetes. Access-specific mortality was incorporated using preexisting cohort data, including terms for age, sex, and diabetes. Costs were ascertained from the 2010 USRDS report and Medicare for procedure costs. An AV fistula attempt strategy was found to be superior to AV grafts and CVCs in regard to mortality and cost for the majority of patient characteristic combinations, especially younger men without diabetes. Women with diabetes and elderly men with diabetes had similar outcomes, regardless of access type. Overall, the advantages of an AV fistula attempt strategy lessened considerably among older patients, particularly women with diabetes, reflecting the effect of lower AV fistula success rates and lower life expectancy. These results suggest that vascular access-related outcomes may be optimized by considering individual patient characteristics.
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Affiliation(s)
- David A Drew
- Department of Medicine, Division of Nephrology and
| | - Charmaine E Lok
- Department of Medicine, Division of Nephrology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Joshua T Cohen
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Martin Wagner
- Institute of Clinical Epidemiology and Biometry and Department of Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany; and
| | - Navdeep Tangri
- Department of Medicine, Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
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17
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Kurella-Tamura M, Goldstein BA, Hall YN, Mitani AA, Winkelmayer WC. State medicaid coverage, ESRD incidence, and access to care. J Am Soc Nephrol 2014; 25:1321-9. [PMID: 24652791 DOI: 10.1681/asn.2013060658] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The proportion of low-income nonelderly adults covered by Medicaid varies widely by state. We sought to determine whether broader state Medicaid coverage, defined as the proportion of each state's low-income nonelderly adult population covered by Medicaid, associates with lower state-level incidence of ESRD and greater access to care. The main outcomes were incidence of ESRD and five indicators of access to care. We identified 408,535 adults aged 20-64 years, who developed ESRD between January 1, 2001, and December 31, 2008. Medicaid coverage among low-income nonelderly adults ranged from 12.2% to 66.0% (median 32.5%). For each additional 10% of the low-income nonelderly population covered by Medicaid, there was a 1.8% (95% confidence interval, 1.0% to 2.6%) decrease in ESRD incidence. Among nonelderly adults with ESRD, gaps in access to care between those with private insurance and those with Medicaid were narrower in states with broader coverage. For a 50-year-old white woman, the access gap to the kidney transplant waiting list between Medicaid and private insurance decreased by 7.7 percentage points in high (>45%) versus low (<25%) Medicaid coverage states. Similarly, the access gap to transplantation decreased by 4.0 percentage points and the access gap to peritoneal dialysis decreased by 3.8 percentage points in high Medicaid coverage states. In conclusion, states with broader Medicaid coverage had a lower incidence of ESRD and smaller insurance-related access gaps.
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Affiliation(s)
- Manjula Kurella-Tamura
- Geriatrics Research Education & Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Division of Nephrology and
| | - Benjamin A Goldstein
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California; and
| | - Yoshio N Hall
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington
| | - Aya A Mitani
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California; and
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18
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Lok CE, Foley R. Vascular Access Morbidity and Mortality: Trends of the Last Decade. Clin J Am Soc Nephrol 2013; 8:1213-9. [DOI: 10.2215/cjn.01690213] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Arteriovenous fistulas (AVFs) are considered the gold standard for hemodialysis vascular access based on their superior patency, low complication rates, improved adequacy, lower costs to the health care system, and decreased risk of patient mortality. The goals of the Fistula First Breakthrough Initiative are to achieve a prevalent AVF use rate of at least 66% nationally, to decrease central venous catheter use, and to reduce overall vascular access complication rates among patients on hemodialysis. Achieving optimal vascular access is a complex process and, unlike other dialysis outcomes, requires patient involvement as well as collaboration among nephrologists, surgeons, interventionalists, dialysis facilities, primary care physicians, and hospital systems. In 2009, the Fistula First Breakthrough Initiative assembled a team from varied backgrounds and perspectives to discover the systemic root causes as to why the AVF use rate in the United States is significantly lower than that in other industrialized countries. Ultimately, the 139 latent root causes identified by the root cause analysis team fall into the categories of patient, physician, and system. This article summarizes the current controversies in regard to improving AVF placement and reducing central venous catheter use, related to each of these three categories.
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Affiliation(s)
- Ionel Z Donca
- Division of Nephrology, University Hospitals Case Medical Center, Cleveland, OH 44106, USA
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20
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Gomes A, Schmidt R, Wish J. Re-envisioning Fistula First in a patient-centered culture. Clin J Am Soc Nephrol 2013; 8:1791-7. [PMID: 23744004 DOI: 10.2215/cjn.03140313] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The main options for vascular access in hemodialysis patients are arteriovenous fistulas (AVFs), arteriovenous grafts, and tunneled cuffed central venous catheters. AVFs have the lowest complication rate and require the fewest interventions and lowest cost to maintain. There has been a dramatic national increase in prevalent AVFs among patients with ESRD in the United States driven, in part, by the Fistula First Breakthrough Initiative. The Fistula First Breakthrough Initiative has engaged stakeholders in the dialysis community to disseminate best practices and quality improvement activities to increase AVF prevalence in suitable candidates. In the pursuit of maximizing AVF placement and prevalence, less emphasis has been placed on the individual patient context. An AVF may not be the best access choice in a subset of patients, particularly those with poor long-term prognoses or comorbid chronic diseases with a short life expectancy, those patients more likely to die than to have their CKD progress to ESRD requiring dialysis, and those with vascular anatomy not amenable to successful AVF placement. Placement of an AVF in these patients subjects them to uncomfortable and likely unnecessary and/or unsuccessful surgeries at an expense, while doing little to improve their clinical outcome or their individual experience of care. AVF prevalence as a pay-for-performance measure without the appropriate case-mix adjustment may penalize providers for accepting higher-risk patients. Although a functioning AVF that provides reliable hemodialysis remains the gold standard for vascular access for most patients, it may not be the most suitable option for every patient.
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Affiliation(s)
- Amanda Gomes
- Division of Nephrology, University Hospitals Case Medical Center, Cleveland, Ohio, †Section of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia
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Gupta N, Cannon M, Srinivasan A. National agenda for prevention of healthcare-associated infections in dialysis centers. Semin Dial 2013; 26:376-83. [PMID: 23682791 DOI: 10.1111/sdi.12091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Healthcare-associated infections (HAIs) are among the leading causes of morbidity and mortality in dialysis patients. To coordinate HAI prevention efforts, the U.S. Department of Health and Human Services established the National Action Plan to Prevent Healthcare Associated Infections in End-Stage Renal Disease Facilities. This comprehensive plan prioritizes HAI prevention practices and 5-year evaluation targets based on the burden of disease, level of scientific evidence, and anticipated impact from the recommended intervention. As such, the Plan focuses primarily on interventions to reduce vascular access-related complications and infections with hepatitis B and hepatitis C virus. Over the last decade, there have been several efforts to expand HAI surveillance and prevention efforts, including coordination of HAI reporting metrics across multiple national agencies, changes in financial incentives by the Centers for Medicare & Medicaid Services (CMS), and federal funding for expansion of state-based HAI prevention programs. As a result, a paradigm shift in HAI prevention has developed. Public health officials have assumed greater responsibility in reducing the burden of HAIs and healthcare providers have become more involved in HAI prevention. Since the Plan was initially drafted, several collaborative efforts in dialysis facilities have reported a reduction in HAIs through implementation of these interventions. These early successes highlight the potential impact of coordinated action to combat HAIs in dialysis settings and this National Action Plan provides evidence-based strategies on how best to achieve this.
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Affiliation(s)
- Neil Gupta
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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22
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Coentrão LA, Araújo CS, Ribeiro CA, Dias CC, Pestana MJ. Cost analysis of hemodialysis and peritoneal dialysis access in incident dialysis patients. Perit Dial Int 2013; 33:662-70. [PMID: 23455977 DOI: 10.3747/pdi.2011.00309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Although several studies have demonstrated the economic advantages of peritoneal dialysis (PD) over hemodialysis (HD), few reports in the literature have compared the costs of HD and PD access. The aim of the present study was to compare the resources required to establish and maintain the dialysis access in patients who initiated HD with a tunneled cuffed catheter (TCC) or an arteriovenous fistula (AVF) and in patients who initiated PD. METHODS We retrospectively analyzed the 152 chronic kidney disease patients who consecutively initiated dialysis treatment at our institution in 2008 (HD-AVF, n = 65; HD-CVC, n = 45; PD, n = 42). Detailed clinical and demographic information and data on access type were collected for all patients. A comprehensive measure of total dialysis access costs, including surgery, radiology, hospitalization for access complications, physician costs, and transportation costs was obtained at year 1 using an intention-to-treat approach. All resources used were valued using 2010 prices, and costs are reported in 2010 euros. RESULTS Compared with the HD-AVF and HD-TCC modalities, PD was associated with a significantly lower risk of access-related interventions (adjusted rate ratios: 1.572 and 1.433 respectively; 95% confidence intervals: 1.253 to 1.891 and 1.069 to 1.797). The mean dialysis access-related costs per patient-year at risk were €1171.6 [median: €608.8; interquartile range (IQR): €563.1 - €936.7] for PD, €1555.2 (median: €783.9; IQR: €371.4 - €1571.7) for HD-AVF, and €4208.2 (median: €1252.4; IQR: €947.9 - €2983.5) for HD-TCC (p < 0.001). In multivariate analysis, total dialysis access costs were significantly higher for the HD-TCC modality than for either PD or HD-AVF (β = -0.53; 95% CI: -1.03 to -0.02; and β = -0.50; 95% CI: -0.96 to -0.04). CONCLUSIONS Compared with patients initiating HD, those initiating PD required fewer resources to establish and maintain a dialysis access during the first year of treatment.
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Affiliation(s)
- Luis A Coentrão
- Nephrology Research and Development Unit1 and Financial Management Unit,2 São João Hospital Centre, and Department of Health Information and Decision Sciences,3 Faculty of Medicine, University of Porto, Portugal
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Leermakers J, Bode A, Vaidya A, van der Sande F, Evers S, Tordoir J. Cost-effectiveness of Vascular Access for Haemodialysis: Arteriovenous Fistulas Versus Arteriovenous Grafts. Eur J Vasc Endovasc Surg 2013; 45:84-92. [DOI: 10.1016/j.ejvs.2012.10.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 10/15/2012] [Indexed: 11/28/2022]
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Xue H, Ix JH, Wang W, Brunelli SM, Lazarus M, Hakim R, Lacson E. Hemodialysis access usage patterns in the incident dialysis year and associated catheter-related complications. Am J Kidney Dis 2012; 61:123-30. [PMID: 23159234 DOI: 10.1053/j.ajkd.2012.09.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 09/27/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hemodialysis (HD) access is considered a critical and actionable determinant of morbidity, with a growing literature suggesting that initial HD access type is an important marker of long-term outcomes. Accordingly, we examined HD access during the incident dialysis period, focusing on infection risk and successful fistula creation during the first dialysis year. STUDY DESIGN Longitudinal cohort. SETTING & PARTICIPANTS All US adults admitted to Fresenius Medical Care North America facilities within 15 days of first maintenance dialysis session between January 1 and December 31, 2007. PREDICTOR Vascular access type at HD therapy initiation. OUTCOMES Vascular access type at 90 days and at the end of the first year on HD therapy, bloodstream infection within the first year by access type, and catheter complication rate. RESULTS Of 25,003 incident dialysis patients studied, 19,622 (78.5%) initiated dialysis with a catheter; 4,151 (16.6%), with a fistula; and 1,230 (4.9%), with a graft. At 90 days, 14,105 (69.7%) had a catheter, 4,432 (21.9%) had a fistula, and 1,705 (8.4%) had a graft. Functioning fistulas and grafts at dialysis therapy initiation had first-year failure rates of 10% and 15%, respectively. Grafts were seldom replaced by fistulas (3%), whereas 7,064 (47.6%) of all patients who initiated with a catheter alone still had only a catheter at 1 year. Overall, 3,327 (13.3%) patients had at least one positive blood culture during follow-up, with the risk being similar between the fistula and graft groups, but approximately 3-fold higher in patients with a catheter (P<0.001 for either comparison). Nearly 1 in 3 catheters (32.5%) will require tissue plasminogen activator use by a median of 41 days, with 59% requiring more than one tissue plasminogen activator administration. LIMITATIONS Potential underestimation of bacteremia because follow-up blood culture results did not include samples sent to local laboratories. CONCLUSIONS In a large and representative population of incident US dialysis patients, catheter use remains very high during the first year of HD care and is associated with high mechanical complication and bloodstream infection rates.
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Affiliation(s)
- Hui Xue
- Division of Hospital Medicine, Department of Medicine, University of California San Diego, San Diego, CA, USA.
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