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Starting hemodialysis with catheter and mortality risk: persistent association in a competing risk analysis
Ramon Roca-Tey1,2, Emma Arcos3, Jordi Comas3
1Coordinator of the Vascular Accesses Working Group of the Catalan Society of Nephrology (SCN), Barcelona - Spain.
Insights
Using a catheter for hemodialysis (HD) significantly increases mortality risk, especially early on. Early placement of an arteriovenous fistula can improve survival rates for incident HD patients.
Area of Science:
- Nephrology
- Vascular Surgery
- Public Health
Background:
- Vascular access (VA) choice at hemodialysis (HD) initiation impacts patient survival.
- Catheter use is associated with higher mortality risks compared to fistulas or grafts.
Purpose of the Study:
- To analyze the survival rates of incident HD patients based on their initial vascular access.
- To evaluate the vascular access profile of patients who died within the first year of HD.
Main Methods:
- Retrospective analysis of 9956 incident HD patients from the Catalan Registry over 12 years.
- Multivariate competing risk model to assess all-cause mortality associated with different VAs.
- Comparison of mortality rates during early (0-120 days) and late (121-365 days) periods of the first year.
Main Results:
- Over 12 years, 47.9% of patients started HD with a fistula, while 35% used untunneled and 15.9% tunneled catheters.
- Catheter use (tunneled and untunneled) was associated with significantly higher hazard ratios for all-cause mortality compared to fistulas.
- In the early period, untunneled and tunneled catheters showed substantially increased odds ratios for all-cause, cardiovascular, and infection-related deaths.
Conclusions:
- Approximately half of incident HD patients in Catalonia face excessive mortality risk due to catheter use.
- Early placement of arteriovenous fistulas is recommended to mitigate this elevated mortality risk.
- Optimizing VA selection at HD initiation is crucial for improving patient outcomes.
Purpose:
The vascular access (VA) used at hemodialysis (HD) inception is involved in the mortality risk. We analyzed the survival of incident patients over time according to the initial VA and the VA profile of patients who died during the first year of follow-up.
Methods:
Data of VA were obtained from 9956 incident HD patients from the Catalan Registry.
Results:
Over 12 years, 47.9% of patients initiated HD with a fístula, 1.2% with a graft, 15.9% with a tunneled catheter and 35% with an untunneled catheter. Regarding fistula use, the hazard ratio of death for all-causes over time when applying a multivariate competing risk model was 1.55 [95% confidence interval (CI): 1.42-1.69] and 1.43 (95% CI: 1.33-1.54) for patients with tunneled and untunneled catheter, respectively. During the first year of follow-up, the crude all-cause mortality rate (deaths/100 patient-years) was higher during the early (first 120 days) compared to the late (121-365 days) period: 18.3 (95% CI: 16.8-19.8) versus 15.4 (95% CI: 14.5-16.5). Regarding fistula use, for patients using untunneled and tunneled catheter, the odds ratio of death in the early period for all-causes was 3.66 (95% CI: 2.80-4.81) and 2.97 (95% CI: 2.17-4.06), for cardiovascular causes it was 2.76 (95% CI: 1.90-4.01) and 1.84 (95% CI: 1.17-2.89) and for infection-related causes it was 6.62 (95% CI: 3.11-14.05) and 4.58 (95% CI: 2.00-10.52), respectively.
Conclusions:
Half of all incident patients in Catalonia are exposed to excessive mortality risk related to catheter and this scenario can be improved by early fistula placement.
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