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Trends in Vascular Access Placement among Patients Initiating Hemodialysis with a Catheter
Michael Allon1, Yi Zhang2, Mae Thamer2
1Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
Insights
Placement of arteriovenous fistula (AVF) or graft (AVG) within six months of starting hemodialysis has decreased significantly. This trend contradicts guidelines and worsens access issues for patients relying on central venous catheters (CVC).
Area of Science:
- Nephrology
- Vascular Surgery
- Public Health
Background:
- Vascular access guidelines prioritize arteriovenous fistula (AVF) or graft (AVG) over central venous catheters (CVC) to prevent complications.
- Recent trends show a decline in pre-dialysis AVF placement and an increase in patients initiating hemodialysis with CVCs only.
Purpose of the Study:
- To evaluate the trend of AVF or AVG placement within the first six months after initiating hemodialysis.
- To determine if this post-initiation access placement offsets the rise in CVC-only starts.
Main Methods:
- Retrospective cohort study utilizing the United States Renal Data System (USRDS).
- Analysis of 522,598 patients initiating hemodialysis with a CVC between 2016 and 2022.
- Outcome measured: proportion of patients with AVF or AVG placement within 6 months of dialysis initiation.
Main Results:
- The proportion of patients starting hemodialysis with CVC only increased from 62% (2016) to 74% (2022).
- AVF/AVG placement within six months declined from 34% (2016) to 26% (2022).
- Adjusted analysis revealed a marked decline in AVF/AVG placement rates starting in 2019, with a cumulative incidence decrease from 15% to 11% by 2022.
Conclusions:
- A significant secular decrease (nearly one-third) in AVF/AVG placement occurred among patients initiating hemodialysis with CVC.
- This decline exacerbates existing issues with inadequate vascular access placement prior to dialysis initiation.
- Findings highlight a critical gap between practice and national vascular access guidelines.
Key Points:
Between 2016 and 2022 the proportion of US patients starting hemodialysis with a catheter increased from 62% to 74%. Concurrently, placement of a fistula or graft in the first 6 months of dialysis decreased from 34% to 26%. After adjustment for baseline characteristics and patient mortality, fistula or graft placement was 31% lower in 2022 than in 2016.
Background:
Vascular access practice guidelines recommend placement of a permanent vascular access-arteriovenous fistula (AVF) or graft (arteriovenous graft [AVG])-to avoid complications associated with central venous catheter (CVC). Despite these guidelines, there has been a recent decrease in predialysis AVF placement and an increase in patients starting hemodialysis with a CVC only. We evaluated whether there has been an increase in the placement of an AVF or AVG in the first 6 months after dialysis initiation to offset the increase in patients starting dialysis with a CVC.
Methods:
This was a retrospective cohort study using the United States Renal Data System. We identified 522,598 patients initiating hemodialysis with a CVC between 2016 and 2022. The exposure was the calendar year of hemodialysis initiation, and the main outcome was the proportion of patients with placement of an AVF or AVG within 6 months of hemodialysis initiation.
Results:
The proportion of patients initiating hemodialysis with a CVC only increased from 62% in 2016 to 74% in 2022 ( P < 0.001), while the proportion receiving an AVF or AVG within 6 months of dialysis initiation declined from 34% to 26% ( P < 0.001). In adjusted Fine-Gray competing risk analysis, compared with 2016 as the reference year, hazard ratios for AVF/AVG placement declined markedly beginning in 2019 (subdistribution hazard ratio, 0.89; 95% confidence interval, 0.87 to 0.90 in 2019; 0.77, 0.76 to 0.78 in 2020; 0.75, 0.74 to 0.76 in 2021; and 0.69, 0.68 to 0.70 in 2022). The standardized 6-month cumulative incidence of AVF/AVG placement decreased from 15% in 2016 to 11% in 2022 ( P < 0.001).
Conclusions:
Contrary to national vascular access guidelines, there has been a nearly one-third secular decrease in placement of an AVF or AVG among patients initiating hemodialysis with a CVC, compounding the lower rates of access placement prior to dialysis initiation.
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