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. 2015 Jan;26(1):183-91.
doi: 10.1681/ASN.2013111236. Epub 2014 Jul 25.

Vascular access choice in incident hemodialysis patients: a decision analysis

David A Drew  1 , Charmaine E Lok  2 , Joshua T Cohen  3 , Martin Wagner  4 , Navdeep Tangri  5 , Daniel E Weiner  6
Affiliations

Vascular access choice in incident hemodialysis patients: a decision analysis

David A Drew et al. J Am Soc Nephrol. 2015 Jan.

Abstract

Hemodialysis vascular access recommendations promote arteriovenous (AV) fistulas first; however, it may not be the best approach for all hemodialysis patients, because likelihood of successful fistula placement, procedure-related and subsequent costs, and patient survival modify the optimal access choice. We performed a decision analysis evaluating AV fistula, AV graft, and central venous catheter (CVC) strategies for patients initiating hemodialysis with a CVC, a scenario occurring in over 70% of United States dialysis patients. A decision tree model was constructed to reflect progression from hemodialysis initiation. Patients were classified into one of three vascular access choices: maintain CVC, attempt fistula, or attempt graft. We explicitly modeled probabilities of primary and secondary patency for each access type, with success modified by age, sex, and diabetes. Access-specific mortality was incorporated using preexisting cohort data, including terms for age, sex, and diabetes. Costs were ascertained from the 2010 USRDS report and Medicare for procedure costs. An AV fistula attempt strategy was found to be superior to AV grafts and CVCs in regard to mortality and cost for the majority of patient characteristic combinations, especially younger men without diabetes. Women with diabetes and elderly men with diabetes had similar outcomes, regardless of access type. Overall, the advantages of an AV fistula attempt strategy lessened considerably among older patients, particularly women with diabetes, reflecting the effect of lower AV fistula success rates and lower life expectancy. These results suggest that vascular access-related outcomes may be optimized by considering individual patient characteristics.

Keywords: dialysis access; hemodialysis; survival.

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Figures

Figure 1.
Figure 1.
Concept model of simulated progression across vascular access options beginning at hemodialysis initiation. Death can be reached from all states; in all failure states, dialysis persists with a CVC. Dashed lines represent failure to achieve or loss of access patency. AVF, AV fistula; AVG, AV graft.
Figure 2.
Figure 2.
Patient survival by access attempt strategy. Plots are stratified by sex and diabetes status. The x axis represents the age in years of modeled patients. The y axis represents the survival in years for modeled patients. Patient survival in years by age stratified by sex and diabetes status. AVF, AV fistula; AVG, AV graft; cath, CVC.
Figure 3.
Figure 3.
Total life time in US dollars by access attempt strategy. Plots are stratified by sex and diabetes status. The x axis represents the age in years of modeled patients. The y axis represents the total lifetime cost in US dollars for modeled patients. Total costs in United States dollars for vascular access strategies by age stratified by sex and diabetes status. AVF, AV fistula; AVG, AV graft; cath, CVC.
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Comment in

  • Catheter last, fistula not-so-first.
    Wish JB. Wish JB. J Am Soc Nephrol. 2015 Jan;26(1):5-7. doi: 10.1681/ASN.2014060594. Epub 2014 Jul 25. J Am Soc Nephrol. 2015. PMID: 25063435 Free PMC article. No abstract available.

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