Trends in incident hemodialysis access and mortality

Mahmoud B. Malas, Joseph K. Canner, Caitlin W. Hicks, Isibor J. Arhuidese, Devin S. Zarkowsky, Umair Qazi, Eric B. Schneider, James H. Black, Dorry L. Segev, Julie A. Freischlag

Research output: Contribution to journalArticle

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Abstract

IMPORTANCE: Based on evidence of survival benefit when initiating hemodialysis (HD) via arteriovenous fistula (AVF) or arteriovenous graft (AVG) vs hemodialysis catheter (HC), the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative published practice guidelines in 1997 recommending 50% or greater AVF rates in incident HD patients. A decade after, lapses exist and the impact on HD outcomes is uncertain. OBJECTIVE: To assess the achievement of the practice goals for incident vascular access and the effects on HD outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted using the US Renal Data System. All patients with end-stage renal disease in the United States without prior renal replacement therapy who had incident vascular access for HD created between January 1, 2006, and December 31, 2010 (N = 510 000) were included. MAIN OUTCOMES AND MEASURES: Incident vascular access use rates and mortality. Relative mortality was quantified using multivariable Cox proportional hazard models. Coarsened exact matching and propensity score-matching techniques were used to better account for confounding by indication. RESULTS: Of 510 000 patients included in this study, 82.6% initiated HD via HC, 14.0% via AVF, and 3.4% via AVG. Arteriovenous fistula use increased only minimally, from 12.2% in 2006 to 15.0% in 2010. Patients initiating HD with AVF had 35% lower mortality than those with HC (adjusted hazard ratio, 0.65; 95% CI, 0.64-0.66; P < .001). Those initiating HD with AVF had 23% lower mortality than those initiating with an HC while awaiting maturation of an AVF (adjusted hazard ratio, 0.77; 95% CI, 0.76-0.79; P < .001). CONCLUSIONS AND RELEVANCE: Current incident AVF practice falls exceedingly short years after recommendations were made in 1997. The impact of this shortcoming on mortality for patients with end-stage renal disease is enormous. Functioning permanent access at initiation of HD confers lower mortality even compared with patients temporized with an HC while awaiting maturation of permanent access. A change of current policies and structured multidisciplinary efforts are required to establish matured fistulae prior to HD to ameliorate this deficit in delivering care.

Original languageEnglish (US)
Pages (from-to)441-448
Number of pages8
JournalJAMA Surgery
Volume150
Issue number5
DOIs
StatePublished - May 1 2015

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Renal Dialysis
Arteriovenous Fistula
Mortality
Catheters
Blood Vessels
Chronic Kidney Failure
Transplants
Kidney
Propensity Score
Renal Replacement Therapy
Kidney Diseases
Practice Guidelines
Proportional Hazards Models
Information Systems
Fistula
Cohort Studies
Retrospective Studies

ASJC Scopus subject areas

  • Surgery

Cite this

Malas, M. B., Canner, J. K., Hicks, C. W., Arhuidese, I. J., Zarkowsky, D. S., Qazi, U., ... Freischlag, J. A. (2015). Trends in incident hemodialysis access and mortality. JAMA Surgery, 150(5), 441-448. https://doi.org/10.1001/jamasurg.2014.3484

Trends in incident hemodialysis access and mortality. / Malas, Mahmoud B.; Canner, Joseph K.; Hicks, Caitlin W.; Arhuidese, Isibor J.; Zarkowsky, Devin S.; Qazi, Umair; Schneider, Eric B.; Black, James H.; Segev, Dorry L.; Freischlag, Julie A.

In: JAMA Surgery, Vol. 150, No. 5, 01.05.2015, p. 441-448.

Research output: Contribution to journalArticle

Malas, MB, Canner, JK, Hicks, CW, Arhuidese, IJ, Zarkowsky, DS, Qazi, U, Schneider, EB, Black, JH, Segev, DL & Freischlag, JA 2015, 'Trends in incident hemodialysis access and mortality', JAMA Surgery, vol. 150, no. 5, pp. 441-448. https://doi.org/10.1001/jamasurg.2014.3484
Malas MB, Canner JK, Hicks CW, Arhuidese IJ, Zarkowsky DS, Qazi U et al. Trends in incident hemodialysis access and mortality. JAMA Surgery. 2015 May 1;150(5):441-448. https://doi.org/10.1001/jamasurg.2014.3484
Malas, Mahmoud B. ; Canner, Joseph K. ; Hicks, Caitlin W. ; Arhuidese, Isibor J. ; Zarkowsky, Devin S. ; Qazi, Umair ; Schneider, Eric B. ; Black, James H. ; Segev, Dorry L. ; Freischlag, Julie A. / Trends in incident hemodialysis access and mortality. In: JAMA Surgery. 2015 ; Vol. 150, No. 5. pp. 441-448.
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AU - Canner, Joseph K.

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AU - Zarkowsky, Devin S.

AU - Qazi, Umair

AU - Schneider, Eric B.

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AU - Segev, Dorry L.

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N2 - IMPORTANCE: Based on evidence of survival benefit when initiating hemodialysis (HD) via arteriovenous fistula (AVF) or arteriovenous graft (AVG) vs hemodialysis catheter (HC), the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative published practice guidelines in 1997 recommending 50% or greater AVF rates in incident HD patients. A decade after, lapses exist and the impact on HD outcomes is uncertain. OBJECTIVE: To assess the achievement of the practice goals for incident vascular access and the effects on HD outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted using the US Renal Data System. All patients with end-stage renal disease in the United States without prior renal replacement therapy who had incident vascular access for HD created between January 1, 2006, and December 31, 2010 (N = 510 000) were included. MAIN OUTCOMES AND MEASURES: Incident vascular access use rates and mortality. Relative mortality was quantified using multivariable Cox proportional hazard models. Coarsened exact matching and propensity score-matching techniques were used to better account for confounding by indication. RESULTS: Of 510 000 patients included in this study, 82.6% initiated HD via HC, 14.0% via AVF, and 3.4% via AVG. Arteriovenous fistula use increased only minimally, from 12.2% in 2006 to 15.0% in 2010. Patients initiating HD with AVF had 35% lower mortality than those with HC (adjusted hazard ratio, 0.65; 95% CI, 0.64-0.66; P < .001). Those initiating HD with AVF had 23% lower mortality than those initiating with an HC while awaiting maturation of an AVF (adjusted hazard ratio, 0.77; 95% CI, 0.76-0.79; P < .001). CONCLUSIONS AND RELEVANCE: Current incident AVF practice falls exceedingly short years after recommendations were made in 1997. The impact of this shortcoming on mortality for patients with end-stage renal disease is enormous. Functioning permanent access at initiation of HD confers lower mortality even compared with patients temporized with an HC while awaiting maturation of permanent access. A change of current policies and structured multidisciplinary efforts are required to establish matured fistulae prior to HD to ameliorate this deficit in delivering care.

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