Hemodialysis access usage patterns in the incident dialysis year and associated catheter-related complications

Abstract

Background: Hemodialysis (HD) access is considered a critical and actionable determinant of morbidity, with a growing literature suggesting that initial HD access type is an important marker of long-term outcomes. Accordingly, we examined HD access during the incident dialysis period, focusing on infection risk and successful fistula creation during the first dialysis year.

Study design: Longitudinal cohort.

Setting & participants: All US adults admitted to Fresenius Medical Care North America facilities within 15 days of first maintenance dialysis session between January 1 and December 31, 2007.

Predictor: Vascular access type at HD therapy initiation.

Outcomes: Vascular access type at 90 days and at the end of the first year on HD therapy, bloodstream infection within the first year by access type, and catheter complication rate.

Results: Of 25,003 incident dialysis patients studied, 19,622 (78.5%) initiated dialysis with a catheter; 4,151 (16.6%), with a fistula; and 1,230 (4.9%), with a graft. At 90 days, 14,105 (69.7%) had a catheter, 4,432 (21.9%) had a fistula, and 1,705 (8.4%) had a graft. Functioning fistulas and grafts at dialysis therapy initiation had first-year failure rates of 10% and 15%, respectively. Grafts were seldom replaced by fistulas (3%), whereas 7,064 (47.6%) of all patients who initiated with a catheter alone still had only a catheter at 1 year. Overall, 3,327 (13.3%) patients had at least one positive blood culture during follow-up, with the risk being similar between the fistula and graft groups, but approximately 3-fold higher in patients with a catheter (P<0.001 for either comparison). Nearly 1 in 3 catheters (32.5%) will require tissue plasminogen activator use by a median of 41 days, with 59% requiring more than one tissue plasminogen activator administration.

Limitations: Potential underestimation of bacteremia because follow-up blood culture results did not include samples sent to local laboratories.

Conclusions: In a large and representative population of incident US dialysis patients, catheter use remains very high during the first year of HD care and is associated with high mechanical complication and bloodstream infection rates.

Figure 1

Cohort Selection. FMCNA, Fresenius Medical Care North America; FMS, ; HD, hemodialysis; PD, peritoneal dialysis.

Figure 2

Evolution of hemodialysis access in the first year in 25,003 incident HD patients sampled from across the US admitted to Fresenius Medical Care North America facilities between January 1 and December 31, 2007.

Figure 3

Kaplan-Meier curves for time to first positive blood culture among incident hemodialysis patients, by initiating access type for all patients (N=25,003).

Figure 4

Vascular access type and associated risk of bloodstream infection in the first year in incident hemodialysis patients, separated by initiating dialysis access type. Case-mix Cox model adjusted for age, gender, race, diabetes status, body mass index, and comorbidities (diabetes, peripheral vascular disease, coronary artery disease, and congestive heart failure). Case-Mix + Quality Indicator (QI) adjusted for first 30-days include laboratory results for albumin, hemoglobin, phosphorous and eKt/V. BSI, bloodstream infection.

Figure 5

Kaplan-Meier Curve on time to first episode of intervention in hemodialysis patients who initiated dialysis with solely a tunneled catheter, separated by interventions performed. TPA, tissue plasminogen activator.