The Effect of Predialysis Fistula Attempt on Risk of All-Cause and Access-Related Death

Vascular access type and prognosis in elderly hemodialysis patients: a propensity-score-matched study

BACKGROUND

To compare the impact of tunneled cuffed catheters (TCCs) and arteriovenous fistulas (AVFs) on outcomes in elderly hemodialysis (HD) patients.

METHODS

A retrospective matched cohort study was performed. Propensity score matching (PSM) was applied to balance the baseline conditions, and we compared all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCEs), hospitalization, and infection rates between AVF and TCC patients ≥70 years old. Cox survival analysis was used to analyze the risk factors for death.

RESULTS

There were 2119 patients from our center in the Chinese National Renal Data System (CNRDS) between 1 January 2010 and 10 October 2023. Among these patients, 77 TCC patients were matched with 77 AVF patients. There was no significant difference in all-cause mortality between the TCC and AVF groups (30.1/100 vs. 33.3/100 patient-years, p = 0.124). Among the propensity score-matched cohorts, no significant differences in Kaplan-Meier curves were observed between the two groups (log-rank p = 0.242). The TCC group had higher rates of MACCEs, hospitalization, and infection than the AVF group (33.7/100 vs. 29.5/100 patient-years, 101.2/100 vs. 79.5/100 patient-years, and 30.1/100 vs. 14.1/100 patient-years, respectively). Multivariate analysis showed that high Charlson comorbidity index (CCI) score was a risk factor for death.

CONCLUSIONS

There was no significant difference in all-cause mortality between elderly HD patients receiving TCCs and AVFs. Compared with those with a TCC, elderly HD patients with an AVF have a lower risk of MACCEs, hospitalization, and infection.

Surgical and endovascular assisted maturation procedures improve cannulation after arteriovenous fistula creation, but not after arteriovenous graft placement

OBJECTIVE

After creation, arteriovenous fistulae (AVF) and arteriovenous grafts (AVG) can undergo surgical or endovascular assisted maturation (AM) procedures to enable use for hemodialysis. We sought to explore the association of interventions with successful two-needle cannulation (TNC) using the United States Renal Data System (USRDS).

METHODS

Using the 2012-2017 USRDS, we identified patients initiating hemodialysis with tunneled dialysis catheters (TDC). Successful AVF/G use was defined as two-needle cannulation (TNC). Our principal outcome was time to first TNC after AVF/G creation. Death and new access placement were competing events that precluded TNC. Competing-risks regression models were constructed to identify factors associated with cannulation. Logistic regression was used to assess the association between AM procedures and 1-year TNC and also to compare post-cannulation outcomes.

RESULTS

Among 81,143 patients, 15,880 (19.6%) had AVG and 65,263 (80.4%) had AVF. AVG patients were more likely than AVF patients to achieve TNC at 1 year on unadjusted (77.4% vs 64.0%, p < 0.001) and on multivariate analysis (sHR = 2.56 (2.49-2.63), p < 0.001). For AVFs, one AM surgical procedure was associated with improved 1-year TNC rates, but further revisions were not helpful. Endovascular AM procedures were associated with increased AVF TNC rates. Any procedure, surgical or endovascular, was detrimental to achieving TNC for AVGs.Following initial TNC, those accesses that needed AM procedures were associated with higher rates of access failure (AVF: OR = 1.32 (1.21-1.45); AVG: OR = 1.77 (1.500-2.00); p < 0.001), catheter replacement (AVF: OR = 1.27 (1.20-1.34); AVG: OR = 1.56 (1.42-1.71), p < 0.001), and additional endovascular procedures (AVF: 0.75 ± 1.22 no AM vs 1.33 ± 1.62 any AM; AVG: 1.31 ± 1.77 no AM vs 1.96 ± 2.22 any AM; all p < 0.001).

CONCLUSIONS

AVG achieved TNC after creation more reliably than AVF. A single surgery or endovascular procedures for AVFs is associated with greater rates of TNC. For AVGs, any AM procedure is associated with lower cannulation rates, and reinforces the need for careful operative technique.

Care Fragmentation, Social Determinants of Health, and Postoperative Mortality in Older Veterans

INTRODUCTION

Veterans Affairs Surgical Quality Improvement Program (VASQIP) benchmarking algorithms helped the Veterans Health Administration (VHA) reduce postoperative mortality. Despite calls to consider social risk factors, these algorithms do not adjust for social determinants of health (SDoH) or account for services fragmented between the VHA and the private sector. This investigation examines how the addition of SDoH change model performance and quantifies associations between SDoH and 30-d postoperative mortality.

METHODS

VASQIP (2013-2019) cohort study in patients ≥65 y old with 2-30-d inpatient stays. VASQIP was linked to other VHA and Medicare/Medicaid data. 30-d postoperative mortality was examined using multivariable logistic regression models, adjusting first for clinical variables, then adding SDoH.

RESULTS

In adjusted analyses of 93,644 inpatient cases (97.7% male, 79.7% non-Hispanic White), higher proportions of non-veterans affairs care (adjusted odds ratio [aOR] = 1.02, 95% CI = 1.01-1.04) and living in highly deprived areas (aOR = 1.15, 95% CI = 1.02-1.29) were associated with increased postoperative mortality. Black race (aOR = 0.77, CI = 0.68-0.88) and rurality (aOR = 0.87, CI = 0.79-0.96) were associated with lower postoperative mortality. Adding SDoH to models with only clinical variables did not improve discrimination (c = 0.836 versus c = 0.835).

CONCLUSIONS

Postoperative mortality is worse among Veterans receiving more health care outside the VA and living in highly deprived neighborhoods. However, adjusting for SDoH is unlikely to improve existing mortality-benchmarking models. Reduction efforts for postoperative mortality could focus on alleviating care fragmentation and designing care pathways that consider area deprivation. The adjusted survival advantage for rural and Black Veterans may be of interest to private sector hospitals as they attempt to alleviate enduring health-care disparities.

A decade of arteriovenous fistula creations in the ⩾75 years population: Equal opportunity or sub-optimal use of resources

BACKGROUND

The optimal vascular access in the elderly remains contentious in the context of increasingly limited resources and anticipated survival on hemodialysis. Research focus has shifted to include the impact of vascular access on quality of life. This study explored clinical outcomes in individuals aged ⩾75 years who had an arteriovenous fistula (AVF) created in a single center over a 10-year period.

MATERIALS AND METHODS

Demographic and clinical data concerning AVFs created January 2009-December 2019 were identified from a prospective database for retrospective analysis. Outcome measures were AVF patency and failure to mature rates plus overall patient and vascular access survival. The Vascular Access Specific Quality of life measure (VASQoL) was completed in a contemporary cohort aged ⩾75 years established on HD in October 2021.

RESULTS

AVF outcomes were available for 272 patients (93%). The failure to mature (FTM) rate was 36% with the significant predictors of AVF FTM being the creation of a radiocephalic AVF (OR 8.13, 95% CI 8.02-8.52, p < 0.01), female gender (OR 4.84, 95% CI 4.70-5.41, p < 0.01), and a history of peripheral vascular disease (OR 5.25, 95% CI 5.22-6.00, p value = 0.02). Functional patency was associated with a median 12-month survival benefit compared to those whose fistula FTM (p < 0.01). The median patency duration for a functionally patent AVF was 3 years. Elderly patients with a fistula reported a lower quality of life in VASQoL scoring than those with central venous catheters.

CONCLUSIONS

In this cohort, AVF creation in individuals aged ⩾75 years AVFs was associated with comparable AVF patency rates to younger patients. AVF functional patency was associated with superior patient survival compared to those with AVF FTM. A multi-disciplinary surveillance program may help reduce AVF loss. Further work on how vascular access choice impacts quality of life in elderly patients is required.

Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review

BACKGROUND

Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease.

OBJECTIVE

The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process.

METHODS

A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023.

RESULTS

Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early.

CONCLUSIONS

This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.

Effect of insertion site on tunnelled haemodialysis catheter outcomes: an observational study of 967 catheters

BACKGROUND

The right internal jugular vein is the preferred approach to tunnelled haemodialysis catheter placement. However, the effect of the insertion site on long-term catheter outcomes remains uncertain.

AIMS

We aimed to analyse a large cohort of tunnelled haemodialysis catheter placements to compare short-term and long-term results according to central venous catheter location.

METHODS

A retrospective cohort study was performed on consecutive tunnelled catheter insertions at two centres over 7 years. The primary outcome was catheter survival, compared according to the central vein site. We used the Kaplan-Meier curve method and Cox proportional hazards modelling to determine the effect of the catheterisation route on primary patency, adjusted for clinical risk factors for catheter failure.

RESULTS

There were 967 tunnelled dialysis catheter placements in 620 patients. The median survival for right internal jugular vein catheters was 569 days. There were no differences in rates of catheter failure between right internal jugular, left internal jugular (adjusted hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.52-1.21), external jugular (HR, 0.79; CI, 0.33-3.13), subclavian (HR, 0.67; CI, 0.58-2.44) and femoral vein (HR, 1.20; CI, 0.36-1.33) catheters following multivariable analysis. There were no major differences in functionality or complications between the groups.

CONCLUSIONS

This study identified no statistically significant relationship between tunnelled haemodialysis catheter insertion site and catheter survival. The contemporary approach to dialysis vascular access should be tailored to specific patient circumstances.

The clinical journey and healthcare resources required for dialysis access of end-stage kidney disease patients during their first year of hemodialysis

BACKGROUND

Creation and maintenance of dialysis vascular access (VA) is a major component of healthcare resource utilization and cost for patients newly started on hemodialysis (HD). Different VA format arises due to patient acceptance of anticipatory care versus late preparation, and clinical characteristics. This study reviews the clinical journey and resource utilization required for different VA formats in the first year of HD.

METHOD

Data of patients newly commenced on HD between July 2015 and June 2016 were reviewed. Patients were grouped by their VA format: (A) pre-emptive surgically created VA (SCVA), (B) tunneled central venous catheter (CVC) followed by SCVA creation, (C) long-term tunneled CVC only. Clinical events, number of investigations and procedures, hospital admissions, and incurred costs of the three groups were compared.

RESULTS

In the multivariable analysis, the cost incurred by the group A patients had no significant difference to that incurred in the group B patients (p = 0.08), while the cost of group C is significantly lower (p < 0.001). Both the 62.7% of group A with successful SCVA who avoided tunneled CVC usage, and those with a functionally matured SCVA in group B (66.1%), used fewer healthcare resources and incurred less cost for their access compared to those did not (p = 0.01, p = 0.02, respectively) during the first year of HD.

CONCLUSION

With comparable cost, a pre-emptive approach enables avoidance of tunneled CVC. Tunneled CVC only access format incurred lower cost and is suitable for carefully selected patients. Successful maturation of SCVA greatly affects patients' clinical journey and healthcare cost.

Management of an aneurysmal arteriovenous fistula in kidney transplant recipients

Aneurysms remain the most common complication of an arteriovenous fistula created for dialysis access. The management of an aneurysmal arteriovenous fistula (AAVF) in kidney transplant recipients remains contentious with a lack of clear clinical guidelines. Recipients of a functioning graft do not require the fistula for dialysis access, however risk of graft failure and needing the access at a future date must be considered. In this review we outline the current evidence in the assessment and management of a transplant recipient with an AAVF. We will describe our recommended five-step approach to assessing an AAVF in transplant patients; 1.) Define AAVF 2.) Risk assess AAVF 3.) Assess transplant graft function and future graft failure risk 4.) Consider future renal replacement therapy options 5.) Vascular mapping to assess future vascular access options. Then we will describe the current therapeutic options and when they would most appropriately be employed.

The reasons for comparative effectiveness clinical trials of arteriovenous fistula versus graft strategy in older adults on hemodialysis with a catheter

Clinicians and patients are guided by observational studies to make one of the most consequential decisions for patients with advanced kidney disease: the selection of the "right" hemodialysis vascular access. More than a decade ago, a call for randomized clinical trials was made to equitably compare clinical outcomes between arteriovenous (AV) fistulas (AVFs) and AV grafts (AVGs). Mounting evidence suggests that trade-offs between AVF- and AVGrelated outcomes are context dependent. In this article, we summarize four streams of evidence that collectively underpin the burden of equipoise between the two types of AV access in older adults with comorbidities who are on hemodialysis with a central venous catheter.

The impact of vascular access type on survival in haemodialysis: time for a paradigm shift? A prospective cohort study

INTRODUCTION

Although arteriovenous autologous fistula is the vascular access of choice due to better long-term outcome than central venous catheters, the use of central venous catheters is increasing. Our study aims to describe the survival and epidemiological features of a cohort of dialysis patients with a focus on the role of vascular access.

METHODS

Our study comprises a follow-up period from 2001 to 2020 in a single center. Descriptive analysis was performed on baseline data. Moreover, we analysed predictive variables of death with univariable and multivariable logistic regressions. Predictors of survival were analysed by univariable and multivariable Cox regression.

RESULTS

Our analysis includes 754 patients undergoing chronic haemodialysis. In the multivariable logistic regression, the use of tunnelled catheters resulted protective against death from any cause (Odds Ratio 0.43; p = 0.017). In the multivariable Cox analysis, being "late referral" was associated with decreased survival in the first 6 months since haemodialysis start (Hazard Ratio 3.79; p = 0.001). In the subgroup of elderly (age ≥ 75 years) patients (n = 201/472) with a follow up of 7-60 months, multivariable logistic regression showed that tunnelled catheters at the start of haemodialysis were associated with lower mortality (Odds Ratio, 0.25; p = 0.021), whereas vascular disease was found to be the main risk factor for death (Odds Ratio, 5.11; p = 0.000). Moreover, vascular disease was confirmed as the only independent risk factor by Cox analysis (Hazard Ratio, 1.58; p = 0.017).

CONCLUSIONS

In our cohort, mortality was found to be more closely associated with comorbidities than with the type of vascular access. Tunnelled central venous catheters might be a viable option for haemodialysis patients.

The effect of early conversion from central venous catheter to arteriovenous fistula on hospitalization and mortality in incident haemodialysis patients

BACKGROUND

Controversy remains as to whether initiating haemodialysis (HD) with a central venous catheter (CVC) and vascular access conversion are associated with the risk of morbidity and mortality in incident HD patients.

METHODS

At our dialysis centre, the vascular access strategy is to create an arteriovenous fistula (AVF) early and use the AVF to initiate HD. In emergency situations, HD is initiated with a CVC and subsequent conversion from a CVC to an AVF as soon as possible. The effects of early AVF conversion on hospitalization and mortality were analysed.

RESULTS

At HD initiation, 35.42% used AVF, 15.63% used CVC with immature AVF and 48.96% used CVC, and all patients were able to convert from CVC to AVF within approximately 3 months. Compared to starting HD using an AVF, using a CVC was associated with access-related hospitalizations at 2 years, regardless of whether an AVF was created before (incidence rate ratio (IRR) = 3.02, 95% CI 0.89-10.24, p = 0.03) or after (IRR = 4.10, 95% CI 1.55-10.85, p < 0.01) HD initiation. The Kaplan-Meier method showed that the 2-year survival probability was not statistically significant between the three groups (log-rank χ2 = 0.165, p = 0.921). Multivariate Cox proportional hazards regression showed that starting HD with a CVC was not associated with mortality at 2 years (p > 0.05).

CONCLUSION

In this cohort, initiating HD with a CVC was associated with more access-related hospitalizations. Under the impact of an early AVF conversion strategy, despite initiating HD with a CVC, subsequent conversion from a CVC to an AVF within approximately 3 months had no impact on all-cause mortality in incident HD patients.

Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial

BACKGROUND

Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access-fistula (AVF) or graft (AVG)-to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers.

METHODS

This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections-defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients' experiences with vascular access care between the two treatment groups.

DISCUSSION

In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making.

TRIAL REGISTRATION

This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).

Patient and Clinician Perspectives on Shared Decision Making in Vascular Access Selection: A Qualitative Study

RATIONALE & OBJECTIVE

Collaborative approaches to vascular access selection are being increasingly encouraged to elicit patients' preferences and priorities where no unequivocally superior choice exists. We explored how patients, their caregivers, and clinicians integrate principles of shared decision making when engaging in vascular access discussions.

STUDY DESIGN

Qualitative description.

SETTING & PARTICIPANTS

Semistructured interviews with a purposive sample of patients, their caregivers, and clinicians from outpatient hemodialysis programs in Alberta, Canada.

ANALYTICAL APPROACH

We used a thematic analysis approach to inductively code transcripts and generate themes to capture key concepts related to vascular access shared decision making across participant roles.

RESULTS

42 individuals (19 patients, 2 caregivers, 21 clinicians) participated in this study. Participants identified how access-related decisions follow a series of major decisions about kidney replacement therapy and care goals that influence vascular access preferences and choice. Vascular access shared decision making was strengthened through integration of vascular access selection with dialysis-related decisions and timely, tailored, and balanced exchange of information between patients and their care team. Participants described how opportunities to revisit the vascular access decision before and after dialysis initiation helped prepare patients for their access and encouraged ongoing alignment between patients' care priorities and treatment plans. Where shared decision making was undermined, hemodialysis via a catheter ensued as the most readily available vascular access option.

LIMITATIONS

Our study was limited to patients and clinicians from hemodialysis care settings and included few caregiver participants.

CONCLUSIONS

Findings suggest that earlier, or upstream, decisions about kidney replacement therapies influence how and when vascular access decisions are made. Repeated vascular access discussions that are integrated with other higher-level decisions are needed to promote vascular access shared decision making and preparedness.

Optimising Access Surgery in Senior Haemodialysis Patients (OASIS): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Current evidence on vascular access strategies for haemodialysis patients is based on observational studies that are at high risk of selection bias. For elderly patients, autologous arteriovenous fistulas that are typically created in usual care may not be the best option because a significant proportion of fistulas either fail to mature or remain unused. In addition, long-term complications associated with arteriovenous grafts and central venous catheters may be less relevant when considering the limited life expectancy of these patients. Therefore, we designed the Optimising Access Surgery in Senior Haemodialysis Patients (OASIS) trial to determine the best strategy for vascular access creation in elderly haemodialysis patients.

METHODS AND ANALYSIS

OASIS is a multicentre randomised controlled trial with an equal participant allocation in three treatment arms. Patients aged 70 years or older who are expected to initiate haemodialysis treatment in the next 6 months or who have started haemodialysis urgently with a catheter will be enrolled. To detect and exclude patients with an unusually long life expectancy, we will use a previously published mortality prediction model after external validation. Participants allocated to the usual care arm will be treated according to current guidelines on vascular access creation and will undergo fistula creation. Participants allocated to one of the two intervention arms will undergo graft placement or catheter insertion. The primary outcome is the number of access-related interventions required for each patient-year of haemodialysis treatment. We will enrol 195 patients to have sufficient statistical power to detect an absolute decrease of 0.80 interventions per year.

ETHICS AND DISSEMINATION

Because of clinical equipoise, we believe it is justified to randomly allocate elderly patients to the different vascular access strategies. The study was approved by an accredited medical ethics review committee. The results will be disseminated through peer-reviewed publications and will be implemented in clinical practice guidelines.

TRIAL REGISTRATION NUMBER

NL7933.

PROTOCOL VERSION AND DATE

V.5, 25 February 2021.

Vascular Access and Clinical Outcomes in Underserved Hemodialysis Patients in Mexico

INTRODUCTION

Central venous catheter (CVC) as vascular access in hemodialysis (HD) associates with adverse outcomes. Early CVC to fistula or graft conversion improves these outcomes. While socioeconomic disparities between the USA and Mexico exist, little is known about CVC prevalence and conversion rates in uninsured Mexican HD patients. We examined vascular access practice patterns and their effects on survival and hospitalization rates among uninsured Mexican HD patients, in comparison with HD patients who initiated treatment in the USA.

METHODS

In this retrospective study of incident HD patients at Hospital Civil (HC; Guadalajara, MX) and the Renal Research Institute (RRI; USA), we categorized patients by the vascular access at the first month of HD and after the following 6 months. Factors associated with continued CVC use were identified by a logistic regression model. We developed multivariate Cox proportional hazards models to investigate the effects of access and conversion on mortality and hospitalization over an 18-month follow-up period.

RESULTS

In 1,632 patients from RRI, the CVC prevalence at month 1 was 64% and 97% among 174 HC patients. The conversion rate was 31.7% in RRI and 10.6% in HC. CVC to non-central venous catheter (NON-CVC) conversion reduced the risk of hospitalization in both HC (aHR 0.38 [95% CI: 0.21-0.68], p = 0.001) and RRI (aHR 0.84 [95% CI: 0.73-0.93], p = 0.001). NON-CVC patients had a lower mortality risk in both populations.

DISCUSSION/CONCLUSION

CVC prevalence and conversion rates of CVC to NON-CVC differed between the US and Mexican patients. An association exists between vascular access type and hospitalization and mortality risk. Prospective studies are needed to evaluate if accelerated and systematic catheter use reduction would improve outcomes in these populations.

Microbial Repercussion on Hemodialysis Catheter-Related Bloodstream Infection Outcome: A 2-Year Retrospective Study

Background

Albeit growing technical advances in the design of hemodialysis catheters, intravascular catheter-related bloodstream infection (CRBSI) still represents an utmost clinical challenge to the health-care workers (HCWs). Data regarding the influence of the culprit organism on the scenario of CRBSI in the literature are extremely lacking. Thereby, this research was carried out.

Methods

We undertook a retrospective cohort study over an interval of 2 years, involving patients who underwent regular hemodialysis via catheters in the Renal Dialysis Unit (RDU) of Dr. Soliman Fakeeh Hospital (DSFH), Jeddah, Kingdom of Saudi Arabia (KSA). The study enrolled 139 patients (56.8% females and 43.2% males), with mean age of 60.79 ± 11.45 years.

Results

The aggregate rate of CRBSI was 5.1/1000 catheter days. Amongst the 139 study candidates confirmed of having CRBSI, while 69.8% of CRBSIs were ascribed to Gram-positive cocci, about one-third of the infectious episodes were secondary to Gram-negative bacilli. Interestingly, fever was the most common presentation of S. aureus CRBSI compared to CoNS and Gram-negative bacilli CRBSIs (20.9% versus 12.9% versus 6.5%, p= 0.0001), whereas CRBSIs due to CoNS were presented mainly with rigors (19.4%). Of note, CRBSIs caused by Gram-negative bacilli had a tendency to manifest with unusual symptoms such as vomiting or hypotension. Besides, they were more prone to involve hospitalization or ICU admission. In this study, no mortality was attributed to CRBSIs.

Conclusion

Our study disclosed that the illicit organism has a repercussion on the clinical presentation as well as the fate of CRBSI among hemodialysis patients. This highlights the worth of identifying the infected cases in a periodic manner, to avoid the occurrence of devastating complications. A large body of work from various hemodialysis centers should take place in the near future so as to provide more insight in this perspective.

Shared decision-making in hemodialysis vascular access practice

Shared decision-making (SDM) is a process of collaborative deliberation in the dyadic patient-physician interaction whereby physicians inform the patients about the pros and cons of all available treatment options and reach an agreement with the patients on their preferred treatment plan. In hemodialysis vascular access practice, SDM advocates a deliberative approach based on the existence of reasonable alternatives-that is, arteriovenous fistula, arteriovenous graft, and central venous catheter-so that patients are able to form and share preferences about access options. In spite of its ethical imperative, SDM is not broadly applied in hemodialysis vascular access planning. Physicians and surgeons commonly deliver prescriptive fistula-centered recommendations concerning the approach to vascular access care. This paternalistic approach has been shaped by directions from long-held clinical practice guidelines and is reinforced by financial payment models linked with the prevalence of arteriovenous fistula in patients on hemodialysis. Awareness is growing that what may have initially seemed a medically and surgically appropriate approach might not always be focused on each individual's goals of care. Clinician's recommendations for vascular access often do not sufficiently consider the uncertainty surrounding the potential benefits of the decision or the cumulative impact of the decision on patient's quality of life. In the evolving health care landscape, it is time for the practice of hemodialysis vascular access to shift from a hierarchical doctor-patient approach to patient-centered care. In this article we review the current state of vascular access practice, present arguments why SDM is necessary in vascular access planning, review barriers and potential solutions to SDM implementation, and discuss future research contingent on an effective system of physician-patient participative decision-making in hemodialysis vascular access practice.

The Canadian Women’s Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 4: Sex- and Gender-Unique Disparities: CVD Across the Lifespan of a Woman

Women have unique sex- and gender-related risk factors for cardiovascular disease (CVD) that can present or evolve over their lifespan. Pregnancy-associated conditions, polycystic ovarian syndrome, and menopause can increase a woman’s risk of CVD. Women are at greater risk for autoimmune rheumatic disorders, which play a role in the predisposition and pathogenesis of CVD. The influence of traditional CVD risk factors (eg, smoking, hypertension, diabetes, obesity, physical inactivity, depression, anxiety, and family history) is greater in women than men. Finally, there are sex differences in the response to treatments for CVD risk and comorbid disease processes. In this Atlas chapter we review sex- and gender-unique CVD risk factors that can occur across a woman’s lifespan, with the aim to reduce knowledge gaps and guide the development of optimal strategies for awareness and treatment.

New Frontiers in Vascular Access Practice: From Standardized to Patient-tailored Care and Shared Decision Making

Vascular access planning is critical in the management of patients with advanced kidney disease who elect for hemodialysis for RRT. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal, namely arteriovenous fistula, and least preferred, namely central venous catheter, type of access. This homogenized approach to vascular access care emerged ineffective in the increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge the limitations of standardized care and encourage tailoring vascular access care on the basis of patient and disease characteristics. In this article, we discuss available literature in support of patient-tailored access care on the basis of differences in vascular access outcomes by biologic and social factors-age, sex, and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice cofactors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual on the basis of biologic factors, fluctuating clinical needs, values, and preferences.

Association Between Attempted Arteriovenous Fistula Creation and Mortality in People Starting Hemodialysis via a Catheter: A Multicenter, Retrospective Cohort Study

Background:

In North America, most people start hemodialysis via a central venous catheter (“catheter”). These patients are counseled to undergo arteriovenous fistula (“fistula”) creation within weeks of starting hemodialysis because fistulas are associated with improved survival.

Objectives:

To determine whether attempting to create a fistula in patients who start hemodialysis via a catheter is associated with improved mortality. We also sought to determine whether differences in baseline patient characteristics, vascular procedures for access-related complications, or days in hospital may confound or mediate the relationship between attempted fistula creation and mortality.

Design:

Multicenter, retrospective cohort study.

Setting:

Six dialysis programs located in Ontario, Alberta, and Manitoba.

Patients:

Patients aged ≥18 years who initiated hemodialysis via a catheter between January 1, 2004, and May 31, 2012, who had not had a previous attempt at fistula creation. We excluded those who had a life expectancy less than 1 year, who transitioned to peritoneal dialysis within 6 months of starting dialysis, and people who started hemodialysis via a graft.

Measurements:

Attempted fistula creation, all-cause mortality, patient characteristics and comorbidities, vascular procedures for access-related complications, and days spent in hospital.

Methods:

We used survival methods, including marginal structural models, to account for immortal time bias and time-varying confounding.

Results:

In total, 1832 patients initiated hemodialysis via a catheter during the study period and met inclusion criteria. Of these patients, 565 (31%) underwent an attempt at fistula creation following hemodialysis start. As compared to those who did not receive a fistula attempt, these people were younger, had fewer comorbidities, and were more likely to have started dialysis as an outpatient and to have received pre-dialysis care. In a marginal structural model controlling for baseline characteristics and comorbidities, attempted fistula creation was associated with a significantly lower mortality (hazard ratio [HR] = 0.53; 95% confidence interval [CI] = 0.43-0.66). This effect did not appear to be confounded or mediated by differences in the number of days spent in hospital or vascular procedures for access-related complications. It also remained similar in analyses restricted to patients who survived at least 6 months (HR = 0.60; 95% CI = 0.47-0.77) and to patients who started hemodialysis as an outpatient (HR = 0.48; 95% CI = 0.33-0.68).

Limitations:

There is likely residual confounding and treatment selection bias.

Conclusions:

In this multicenter cohort study, attempting fistula creation in people who started hemodialysis via a catheter was associated with significantly reduced mortality. This reduction in mortality could not be explained by differences in patient characteristics or comorbidities, days spent in hospital, or vascular procedures for access-related complications. Residual confounding or selection bias may explain the observed benefits of fistulas for hemodialysis access.

Trial Registration:

Not applicable (cohort study).

Influence of Tunneled Hemodialysis-Catheters on Inflammation and Mortality in Dialyzed Patients

Older age and comorbidities in hemodialysis patients determines the use of tunneled catheters as vascular access despite their reported clinical and mortality disadvantages. This prospective matched study analyzes the impact of permanent catheters on inflammation and mortality in hemodialysis patients; We studied 108 patients, 54 with AV-fistula (AVF) and 54 with indwelling hemodialysis catheters (HDC) matched by sex, age, diabetes and time under renal-replacement therapy comparing dialysis efficacy, inflammation and micro-inflammation parameters as well as mortality. Cox-regression analysis was applied to determine predictors of mortality, HDC patients presented higher C-reactive-protein (CRP) blood levels and percentage of pro-inflammatory lymphocytes CD14+/CD16+ with worse dialysis-efficacy parameters. Thirty-six-months mortality appeared higher in the HDC group although statistical significance was not reached. Age with a Hazard Ratio (HR) = 1.06, hypoalbuminemia (HR = 0.43), hypophosphatemia (HR = 0.75) and the increase in CD14+/CD16+ monocyte count (HR = 1.02) were predictors of mortality; elder patients dialyzing through HDC show increased inflammation parameters as compared with nAVF bearing patients, although they do not present a significant increase in mortality when matched by covariates. Increasing age and percentage of pro-inflammatory monocytes as well as decreased phosphate and serum-albumin were predictors of mortality and indicate the main conclusions or interpretations.

A call to optimize haemodialysis vascular access care in healthcare disrupted by COVID-19 pandemic

The COVID-19 pandemic has resulted in major disruption to the delivery of both routine and urgent healthcare needs in many institutions across the globe. Vascular access (VA) for haemodalysis (HD) is considered the patient's lifeline and its maintenance is essential for the continuation of a life saving treatment. Prior to the COVID-19 pandemic, the provision of VA for dialysis was already constrained. Throughout the pandemic, inevitably, many patients with chronic kidney disease (CKD) have not received timely intervention for VA care. This could have a detrimental impact on dialysis patient outcomes in the near future and needs to be addressed urgently. Many societies have issued prioritisation to allow rationing based on clinical risk, mainly according to estimated urgency and need for treatment. The recommendations recently proposed by the European and American Vascular Societies in the COVID-19 pandemic era regarding the triage of various vascular operations into urgent, emergent and elective are debatable. VA creation and interventions maintain the lifeline of complex HD patients, and the indication for surgery and other interventions warrants patient-specific clinical judgement and pathways. Keeping the use of central venous catheters at a minimum, with the goal of creating the right access, in the right patient, at the right time, and for the right reasons, is mandatory. These strategies may require local modifications. Risk assessments may need specific "renal pathways" to be developed rather than applying standard surgical risk stratification. In conclusion, in order to recover from the second wave of COVID-19 and prepare for further phases, the provision of the best dialysis access, including peritoneal dialysis, will require working closely with the multidisciplinary team involved in the assessment, creation, cannulation, surveillance, maintenance, and salvage of definitive access.

Arteriovenous Fistula Versus Graft Access Strategy in Older Adults Receiving Hemodialysis: A Pilot Randomized Trial

Background

It is unclear whether surgical placement of an arteriovenous (AV) fistula (AVF) confers substantial clinical benefits over an AV graft (AVG) in older adults with end-stage kidney disease (ESKD). We report vascular access outcomes of a pilot clinical trial.

Study Design

Pilot randomized parallel-group open-label trial.

Setting & Participants

Patients 65 years and older with ESKD and no prior AV access receiving maintenance hemodialysis through a tunneled central venous catheter referred for AV access placement by their treating nephrologist.

Intervention

Participants were randomly assigned in a 1:1 ratio to surgical placement of an AVG or AVF.

Outcomes

Index AV access primary failure, successful cannulation, adjuvant interventions and infections.

Results

Of 122 older adults receiving hemodialysis and no prior AV access surgery, 24% died before (n = 18) or were too sick for (n = 11) referral for a permanent AV access. Of 46 eligible patients, 36 (78%) consented and were randomly assigned to AVG (n = 18) and AVF (n = 18) placement, of whom 13 (72%) and 16 (89%) underwent index AV access surgical placement, respectively. At a median follow-up of 321.0 days, primary AV access failure was noted in 31% in each group. The proportion of patients with successful cannulation was 62% (8 of 13) in the AVG and 50% (8 of 16) in the AVF group; median times to successful cannulation were 75.0 and 113.5 days, respectively. Endovascular procedures were recorded in 38% and 44%, and surgical reinterventions, in 23% and 25%, respectively. AV access infection was seen in 3 (23%) and 2 (13%) patients, respectively.

Limitations

Small sample size precludes statistical inference.

Conclusions

Almost one-quarter of older adults with incident ESKD and a central venous catheter as primary access were not referred for AV access placement due to medical reasons. Based on these limited results, there is little reason to favor either an AVF or AVG in this population until results from a larger randomized clinical trial become available.

Funding

Government funding to an author (Dr Murea is supported by National Institutes of Health∖National Institute on Aging grant 1R03 AG060178-01).

Trial Registration

NCT03545113.

Age is just a number: Is frailty being ignored in vascular access planning for dialysis?

Current international guidelines advocate fistula creation as first choice for vascular access in haemodialysis patients, however, there have been suggestions that in certain groups of patients, in particular the elderly, a more tailored approach is needed. The prevalence of more senior individuals receiving renal replacement therapy has increased in recent years and therefore including patient age in decision making regarding choice of vascular access for dialysis has gained more relevance. However, it seems that age is being used as a surrogate for overall clinical condition and it can be proposed that frailty may be a better basis to considering when advising and counselling patients with regard to vascular access for dialysis. Frailty is a clinical condition in which the person is in a vulnerable state with reduced functional capacity and has a higher risk of adverse health outcomes when exposed to stress inducing events. Prevalence of frailty increases with age and has been associated with an increased risk of mortality, hospitalisation, disability and falls. Chronic kidney disease is associated with premature ageing and therefore patients with kidney disease are prone to be frailer irrespective of age and the risk increases further with declining kidney function. Limited data exists on the relationship between frailty and vascular access, but it appears that frailty may have an association with poorer outcomes from vascular access. However, further research is warranted. Due to complexity in decision making in dialysis access, frailty assessment could be a key element in providing patient-centred approach in planning and maintaining vascular access for dialysis.

Practice patterns of dialysis access and outcomes in patients wait-listed early for kidney transplantation

BACKGROUND

Early kidney transplantation (KT) is the best option for patients with end-stage kidney disease, but little is known about dialysis access strategy in this context. We studied practice patterns of dialysis access and how they relate with outcomes in adults wait-listed early for KT according to the intended donor source.

METHODS

This study from the REIN registry (2002-2014) included 9331 incident dialysis patients (age 18-69) wait-listed for KT before or by 6 months after starting dialysis: 8342 candidates for deceased-donor KT and 989 for living-donor KT. Subdistribution hazard ratios (SHR) of KT and death associated with hemodialysis by catheter or peritoneal dialysis compared with arteriovenous (AV) access were estimated with Fine and Gray models.

RESULTS

Living-donor candidates used pretransplant peritoneal dialysis at rates similar to deceased-donor KT candidates, but had significantly more frequent catheter than AV access for hemodialysis (adjusted OR 1.25; 95%CI 1.09-1.43). Over a median follow-up of 43 (IQR: 23-67) months, 6063 patients received transplants and 305 died before KT. Median duration of pretransplant dialysis was 15 (7-27) months for deceased-donor recipients and 9 (5-15) for living-donor recipients. Catheter use in deceased-donor candidates was associated with a lower SHR for KT (0.88, 95%CI 0.82-0.94) and a higher SHR for death (1.53, 95%CI 1.14-2.04). Only five deaths occurred in living-donor candidates, three of them with catheter use.

CONCLUSIONS

Pretransplant dialysis duration may be quite long even when planned with a living donor. Advantages from protecting these patients from AV fistula creation must be carefully evaluated against catheter-related risks.

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.

Sex differences in the vascular access of hemodialysis patients: a cohort study

Background

We describe differences for probability of receiving a fistula attempt, achieving fistula use, remaining catheter-free and the rate of access-related procedures as a function of sex.

Methods

Prospectively collected vascular access data on incident dialysis patients from five Canadian programs using the Dialysis Measurement Analysis and Reporting System to determine differences in fistula-related outcomes between women and men. The probability of receiving a fistula attempt and the probability of fistula use were determined using binary logistic regression. Catheter and fistula procedure rates were described using Poisson regression. We studied time to fistula attempt and time to fistula use, accounting for competing risks.

Results

We included 1446 (61%) men and 929 (39%) women. Men had a lower body mass index (P < 0.001) and were more likely to have coronary artery disease (P < 0.001) and peripheral vascular disease (p < 0.001). A total of 688 (48%) men and 403 (43%) women received a fistula attempt. Women were less likely to receive a fistula attempt by 6 months {odds ratio [OR] 0.64 [95% confidence interval (CI) 0.52-0.79]} and to achieve catheter-free use of their fistula by 1 year [OR 0.38 (95% CI 0.27-0.53)]. At an average of 2.30 access procedures per person-year, there is no difference between women and men [incidence rate ratio (IRR) 0.97 (95% CI 0.87-1.07)]. Restricting to those with a fistula attempt, women received more procedures [IRR 1.16 (95% CI 1.04-1.30)] attributed to increased catheter procedures [IRR 1.50 (95% CI 1.27-1.78)]. There was no difference in fistula procedures [IRR women versus men 0.96 (95% CI 0.85-1.07)].

Conclusion

Compared with men, fewer women undergo a fistula attempt. This disparity increases after adjusting for comorbidities. Women have the same number of fistula procedures as men but are less likely to successfully use their fistula.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Delayed conversion from central venous catheter to non-catheter hemodialysis access associates with an increased risk of death: A retrospective cohort study based on data from a large dialysis provider

Background

Hemodialysis initiation using a central venous catheter (CVC) poses an increased risk of death. Conversion to an arterio‐venous graft or fistula (AVF, AVG) improves outcomes. The relationship of primary dialysis access and timing of conversion from CVC to either AVF or AVG to all‐cause mortality was investigated.

Methods

Two retrospective analyses in incident hemodialysis patients commencing treatment from January 2010 to December 2014 in dialysis clinics in the United States were conducted. Analysis 1 stratified as per access at initiation and those commencing with CVC were further stratified into (a) those that had a CVC, AVF, or AVG the entire year; (b) those that were converted to either AVF or AVG within either (i) the first or (ii) the second 6 months. Kaplan Meier analysis and Cox regression analysis were employed. Analysis 2 included all CVC patients investigating the relationship between access conversion time and mortality risk using a Cox proportional hazards model depicting the hazard ratio (HR) as a spline function over time.

Results

Two subsets from initial 78,871 patients were studied. In Analysis 1 both AVF (referent) and AVG [HR 1.12 (0.97 to 1.30)] associated with a better outcome than CVC [HR 1.55 (1.38 to 1.74)] during follow‐up. Lower mortality risk was seen for early switch from a CVC to AV access within the first 6 months [HR = 1.04 (0.97–1.13)] compared to a later switch [HR = 1.23 (1.10–1.38)]. Analysis 2 indicated that a CVC to AVF switch resulted in improved survival. Analysis 2 indicated early conversion to confer a survival benefit for CVC to AVG switch.

Discussion and Conclusion

AVF and AVG show a survival benefit over CVC. Early conversion from CVC to either access improves survival. This emphasizes the importance of early preparation for dialysis by creation of an AVF or AVG and to convert CVCs early.

Determinants of Increased Central Excess Pressure in Dialysis: Role of Dialysis Modality and Arteriovenous Fistula

BACKGROUND

Arterial reservoir-wave analysis (RWA)-a new model of arterial hemodynamics-separates arterial wave into reservoir pressure (RP) and excess pressure (XSP). The XSP integral (XSPI) has been associated with increased risk of clinical outcomes. The objectives of the present study were to examine the determinants of XSPI in a mixed cohort of hemodialysis (HD) and peritoneal dialysis (PD) patients, to examine whether dialysis modality and the presence of an arteriovenous fistula (AVF) are associated with increased XSPI.

METHOD

In a cross-sectional study, 290 subjects (232 HD and 130 with AVF) underwent carotid artery tonometry (calibrated with brachial diastolic and mean blood pressure). The XSPI was calculated through RWA using pressure-only algorithms. Logistic regression was used for determinants of XSPI above median. Through forward conditional linear regression, we examined whether treatment by HD or the presence of AVF is associated with higher XSPI.

RESULTS

Patients with XSPI above median were older, had a higher prevalence of diabetes and cardiovascular disease, had a higher body mass index, and were more likely to be on HD. After adjustment for confounders, HD was associated with a higher risk of higher XSPI (odds ratio = 2.39, 95% confidence interval: 1.16-4.98). In a forward conditional linear regression analysis, HD was associated with higher XSPI (standardized coefficient: 0.126, P = 0.012), but on incorporation of AVF into the model, AVF was associated with higher XSPI (standardized coefficient: 0.130, P = 0.008) and HD was excluded as a predictor.

CONCLUSION

This study suggests that higher XSPI in HD patients is related to the presence of AVF.

Comparative Effectiveness of Drug-Coated Balloon vs Balloon Angioplasty for the Treatment of Arteriovenous Fistula Stenosis: A Meta-analysis

Purpose: To compare the effectiveness and safety outcomes of drug-coated balloon angioplasty (DCBA) vs conventional balloon angioplasty (BA) for arteriovenous fistula (AVF) stenosis. Materials and Methods: A systematic review was conducted of PubMed and Embase databases from 1966 to May 2019 to identify English-language articles evaluating DCBA vs BA for the treatment of AVF stenosis. Data extracted from each study were synthesized to evaluate target lesion revascularization (TLR), technical success, and mortality for the 2 approaches. Meta-analyses were performed on these outcomes using random effects models to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup and sensitivity analyses were performed. Results: Twelve studies [6 randomized controlled trials (RCTs) and 6 cohort studies] comprising 979 patients were included in this meta-analysis. The pooled results showed that AVFs treated with DCBA had significantly fewer TLRs at 6 months (OR 0.31, 95% CI 0.14 to 0.69, p=0.004) and 12 months (OR 0.45, 95% CI 0.21 to 0.97, p=0.04) than BA. The 2 approaches had similar technical success rates (OR 0.22, 95% CI 0.03 to 1.43, p=0.11). Additionally, the pooled OR of 12-month mortality was 0.71 (95% CI 0.20 to 2.51, p=0.60), indicating no significant difference between DCBA and BA. Subgroup analysis based on study design showed the superiority of DCBA to BA in cohort studies but not RCTs, which had high heterogeneity. Significant publication bias was found in the cohort studies. Conclusion: In de novo or recurrent AVF stenosis, DCBA appears to be an effective procedure associated with lower 6- and 12-month TLR compared with BA. However, larger and randomized controlled studies are warranted to draw definitive conclusions.

Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population

BACKGROUND

Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC).

METHODS

To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013.

RESULTS

At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft.

CONCLUSIONS

Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.

Complications of arteriovenous fistula in dialysis patients: Incidence and risk factors in Taif city, KSA

AIM

The aim of this study was to measure the prevalence of arteriovenous fistula (AVF) and its complications in patients undergoing hemodialysis (HD) in Taif Region, Saudi Arabia.

METHODS

This was a prospective hospital-based study conducted on 196 patients aged above 18 years who were undergoing dialysis in two hospital Taif City. Data collected and documented using a pretested questionnaire, which included sociodemographic details and also information about fistula-related complications. Hospital records were also reviewed to match the complication and related risk factors. Appropriate statistical tests were used and analyzed with SPSS software ver. 23.

RESULTS

Majority of the study patients were in the age group of 41-60 years and the prevalence in male and female were 49.5% and 50.5%, respectively. The most prevalent chronic illness in the patients was hypertension (41.7%) and more than 30.6% had multiple chronic illness. The most common type of AVF was radiocephalic fistula (RCF). The most common complication associated with the patients with AVF was ischemic neuropathy (29.6%). Smokers had significant history of myocardial infarction than non smokers.

CONCLUSION

Early and timely detection of complications in AVF is essential for proper management. Health professional should have thorough knowledge regarding the complications related to AVF. Early diagnosis and appropriate treatment are essential to improve the quality of life in patients on HD.

Hemodialysis access cost comparisons among incident tunneled catheter patients

Background:

Arteriovenous fistula is the ideal hemodialysis access, but most patients start with tunneled dialysis catheter. Arteriovenous fistula and arteriovenous graft surgery may reduce tunneled dialysis catheter use and also increase procedural expenses. We compared Medicare costs associated with arteriovenous fistula, arteriovenous graft, and tunneled dialysis catheter.

Methods:

Using the US Renal Data System, we identified incident hemodialysis patients in 2008 who started with tunneled dialysis catheter, survived at least 90 days, and had adequate Medicare records for analysis. We followed them until death or end of 2011; access modality was based on billing evidence of arteriovenous fistula or arteriovenous graft creation. We assumed patients without such records remained with tunneled dialysis catheter. We generated multivariate linear regression models predicting Medicare expenditures, censoring costs when patients died; we included all payments to physicians and institutions. We also created algorithms to identify access-related costs.

Results:

There were 113,505 patients in the US Renal Data System who started hemodialysis in 2008, of whom 51,002 Medicare patients met inclusion criteria. Of that group, 41,532 (81%) began with tunneled dialysis catheter; 27,064 patients were in the final analysis file. In the first 90 days after hemodialysis initiation, 6100 (22.5%) received arteriovenous fistula, 1813 (6.7%) arteriovenous graft, and 19,151 (70.8%) stayed with tunneled dialysis catheter. Annualized access costs by modality were tunneled dialysis catheter US$13,625 (95% confidence interval: US$13,426–US$13,285); arteriovenous fistula US$16,864 (95% confidence interval: US$16,533–US$17,194); and arteriovenous graft US$20,961 (95% confidence interval: US$20,967–US$21,654; p < .001). Multivariate linear regression demonstrated that staying with tunneled dialysis catheter had lowest access-related costs, arteriovenous fistula was intermediate, and those who underwent arteriovenous graft surgery were highest (p < .021). Access type was not significantly associated with total costs. Additional arteriovenous fistula and arteriovenous graft creation (US$3525 and US$3804 per access per year, respectively) and open and endovascular access-related interventions (US$3102 and US$3569 per procedure per year, respectively; all p < .001) were important predictors of increased cost.

Conclusions:

Among patients starting hemodialysis with tunneled dialysis catheter, continued tunneled dialysis catheter use is associated with lowest access-related cost. Both endovascular and open interventions are associated with significant additional costs. Further investigation is warranted to develop efficient patient-centered strategies for hemodialysis access.

Initiation of maintenance hemodialysis through central venous catheters: study of patients' perceptions based on a structured questionnaire

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.

Complications of Hemodialysis Catheter Bloodstream Infections: Impact of Infecting Organism

BACKGROUND

Catheter-related bloodstream infections -(CRBSI) are associated with a high burden of morbidity and mortality, but the impact of infecting organism on clinical outcomes has been poorly studied.

METHODS

This retrospective analysis of a prospective vascular access database from a large academic dialysis center investigated whether the organism type affected the clinical presentation or complications of CRBSI.

RESULTS

Among 339 patients with suspected CRBSI, an alternate source of infection was identified in 50 (15%). Of 289 patients with CRBSI, 249 grew a single organism and 40 were polymicrobial. Fever and/or rigors were presenting signs in ≥90% of patients with Staphylococcus aureus or Gram-negative CRBSI, but only 61% of Staphylococcus epidermidis infections (p < 0.001). Hospitalization occurred in 67% of patients with S. aureus CRBSI versus 34% of those with S. epidermidis and 40% of those with a Gram-negative bacteria (p < 0.001). Admission to the intensive care unit was required in 14, 9, and 2% (p = 0.06); metastatic infection occurred in 10, 4, and 4% (p = 0.42); and median length of stay among patients admitted to the hospital was 4, 4, and 5.5 days (p = 0.60), respectively. Death due to CRBSI occurred in only 1% of patients with CRBSI.

CONCLUSION

CRBSI is confirmed in 85% of catheter-dependent hemodialysis patients in whom it is suspected. S. epidermidis CRBSI tends to present with atypical symptoms. S. aureus CRBSI is more likely to require hospitalization or intensive care admission. Metastatic infection is relatively uncommon, and death due to CRBSI is rare.

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes.

Timing of Fistula Creation and the Probability of Catheter-Free Use: A Cohort Study

Background:

Fistula creation is recommended to avoid the use of central venous catheters for hemodialysis. The extent to which timing of fistula creation minimizes catheter use is unclear.

Objective:

To compare patient outcomes of 2 fistula creation strategies: fistula attempt prior to the initiation of dialysis (“predialysis”) or fistula attempt after starting dialysis (“postinitiation”).

Design:

Cohort study.

Setting:

Five Canadian dialysis programs.

Patients:

Patients who started hemodialysis between 2004 and 2012, who underwent fistula creation, and were tracked in the Dialysis Measurement Analysis and Reporting (DMAR) system.

Measurements:

Catheter-free fistula use within 1 year of hemodialysis start, probability of catheter-free fistula use during follow-up, and rates of access-related procedures.

Methods:

Retrospective data analysis: logistic regression; negative binomial regression.

Results:

Five hundred and eight patients had fistula attempts predialysis and 583 postinitiation. At 1 year, 80% of those with predialysis attempts achieved catheter-free use compared to 45% with post-initiation attempts (adjusted odds ratio [OR]_preVSpost = 4.67; 95% confidence interval [CI] = 3.28-6.66). The average of all patient follow-up time spent catheter-free was 63% and 28%, respectively (probability of use per unit time, OR_preVSpost = 2.90; 95% CI = 2.18-3.85). This finding was attenuated when accounting for maturation time and when restricting the analysis to those who achieved catheter-free use. Predialysis fistula attempts were associated with lower procedure rates after dialysis initiation—1.61 procedures per person-year compared with 2.55—but had 0.65 more procedures per person prior to starting dialysis.

Limitations:

Observational design, unknown indication for predialysis and postinitiation fistula creation, and unknown reasons for prolonged catheter use.

Conclusions:

Predialysis fistula attempts were associated with a higher probability of catheter-free use and remaining catheter-free over time, and also resulted in fewer procedures compared with postinitiation attempts, which could be due to timing of attempt or patient factors. Catheter use and procedures were still common for all patients, regardless of the timing of fistula creation.

Vascular Access for Hemodialysis Patients: New Data Should Guide Decision Making

This commentary critically examines key assumptions and recommendations in the 2006 Kidney Disease Outcomes Quality Initiative vascular access guidelines, and argues that several are not relevant to the contemporary United States hemodialysis population. First, the guidelines prefer arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs), on the basis of their superior secondary survival and lower frequency of interventions and infections. However, intent-to-treat analyses that incorporate the higher primary failure of AVFs, demonstrate equivalent secondary survival of both access types. Moreover, the lower rate of AVF versus AVG infections is counterbalanced by the higher rate of catheter-related bloodstream infections before AVF maturation. In addition, AVFs with assisted maturation (interventions before successful AVF use), which account for about 50% of new AVFs, are associated with inferior secondary patency compared with AVGs without intervention before successful use. Second, the guidelines posit lower access management costs for AVFs than AVGs. However, in patients who undergo AVF or AVG placement after starting dialysis with a central venous catheter (CVC), the overall cost of access management is actually higher in patients receiving an AVF. Third, the guidelines prefer forearm over upper arm AVFs. However, published data demonstrate superior maturation of upper arm versus forearm AVFs, likely explaining the progressive increase in upper arm AVFs in the United States. Fourth, AVFs are thought to fail primarily because of aggressive juxta-anastomotic stenosis. However, recent evidence suggests that many AVFs mature despite neointimal hyperplasia, and that suboptimal arterial vasodilation may be an equally important contributor to AVF nonmaturation. Finally, CVC use is believed to result in excess mortality in patients on hemodialysis. However, recent data suggest that CVC use is simply a surrogate marker of sicker patients who are more likely to die, rather than being a mediator of mortality.

Health Insurance in the First 3 Months of Hemodialysis and Early Vascular Access

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.

Should a fistula first policy be revisited in elderly haemodialysis patients?

Life-sustaining haemodialysis requires a durable vascular access (VA) to the circulatory system. The ideal permanent VA must provide longevity for use with minimal complication rate and supply sufficient blood flow to deliver the prescribed dialysis dosage. Arteriovenous fistulas (AVFs) have been endorsed by many professional societies as the VA of choice. However, the high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and arterial hypertension in elderly people, usually make VA creation more difficult in the elderly. Many of these patients may have an insufficient vasculature for AVF maturation. Furthermore, many AVFs created prior to the initiation of haemodialysis may never be used due to the competing risk of death before dialysis is required. As such, an arteriovenous graft and, in some cases, a central venous catheter, become a valid alternative form of VA. Consequently, there are multiple decision points that require careful reflection before an AVF is placed in the elderly. The traditional metrics of access patency, failure and infection are now being seen in a broader context that includes procedure burden, quality of life, patient preferences, morbidity, mortality and cost. This article of the European Dialysis (EUDIAL) Working Group of ERA-EDTA critically reviews the current evidence on VA in elderly haemodialysis patients and concludes that a pragmatic patient-centred approach is mandatory, thus considering the possibility that the AVF first approach should not be an absolute.

Two-Year Observational Study of Bloodstream Infection Rates in Hemodialysis Facility Patients with and without Catheters

BACKGROUND AND OBJECTIVES

Bloodstream infection rates of patients on hemodialysis with catheters are greater than with other vascular accesses and are an important quality measure. Our goal was to compare relative bloodstream infection rates of patients with and without catheters as a quality parameter among the facilities providing hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used CROWNWeb and National Healthcare Safety Network data from all 179 Medicare facilities providing adult outpatient hemodialysis in New England for >6 months throughout 2015-2016 (mean, 12,693 patients per month). There was a median of 60 (interquartile range, 43-93) patients per facility, with 17% having catheters.

RESULTS

Among the five batch-submitting dialysis organizations, the bloodstream infection rate in patients with a catheter in four organizations had adjusted risk ratios of 1.44 (95% confidence interval, 1.07 to 1.93) to 1.91 (95% confidence interval, 1.39 to 2.63) times relative to the reference dialysis provider group (P<0.001). The percentage of catheters did not explain the difference in bloodstream infection rates among dialysis provider organizations. The bloodstream infection rates in patients with a catheter were negatively correlated with the facility's proportion of this patient group. Facilities with <10%, 10%-14.9%, 15%-19.9%, and ≥20% catheter patients had bloodstream infection rates of 4.4, 2.2, 1.9, and 1.5 per 100 patient-months, respectively, in that patient group (adjusted P<0.001). This difference was not seen in patients without catheters. There was no effect of facility patient census or season of the year.

CONCLUSIONS

A study of the adult outpatient hemodialysis facilities in New England in 2015-2016 found that four dialysis provider groups had significantly higher bloodstream infection rates in patients with a catheter than the best-performing dialysis provider group. Hemodialysis facilities with lower proportions of patients with a catheter have significantly higher bloodstream infection rates in this patient group than facilities with >20% catheters, a finding that did not explain the difference among provider organizations.

Development and Validation of Prediction Scores for Early Mortality at Transition to Dialysis

OBJECTIVE

To develop and validate a risk prediction model that would help individualize treatment and improve the shared decision-making process between clinicians and patients.

PATIENTS AND METHODS

We developed a risk prediction tool for mortality during the first year of dialysis based on pre-end-stage renal disease characteristics in a cohort of 35,878 US veterans with incident end-stage renal disease who transitioned to dialysis treatment between October 1, 2007, and March 31, 2014 and then externally validated this tool among 4284 patients in the Kaiser Permanente Southern California (KPSC) health care system who transitioned to dialysis treatment between January 1, 2007, and September 30, 2015.

RESULTS

To ensure model goodness of fit, 2 separate models were selected for patients whose last estimated glomerular filtration rate (eGFR) before dialysis initiation was less than 15 mL/min per 1.73 m² or 15 mL/min per 1.73 m² or higher. Model discrimination in the internal validation cohort of veterans resulted in C statistics of 0.71 (95% CI, 0.70-0.72) and 0.66 (95% CI, 0.65-0.67) among patients with eGFR lower than 15 mL/min per 1.73 m² and 15 mL/min per 1.73 m² or higher, respectively. In the KPSC external validation cohort, the developed risk score exhibited C statistics of 0.77 (95% CI, 0.74-0.79) in men and 0.74 (95% CI, 0.71-0.76) in women with eGFR lower than 15 mL/min per 1.73 m² and 0.71 (95% CI, 0.67-0.74) in men and 0.67 (95% CI, 0.62-0.72) in women with eGFR of 15 mL/min per 1.73 m² or higher.

CONCLUSION

A new risk prediction tool for mortality during the first year after transition to dialysis (available at www.DialysisScore.com) was developed in the large national Veterans Affairs cohort and validated with good performance in the racially, ethnically, and gender diverse KPSC cohort. This risk prediction tool will help identify high-risk populations and guide management strategies at the transition to dialysis.