Hemodialysis vascular access and subsequent transplantation: a report from the ESPN/ERA-EDTA Registry

Abstract

Background: Current guidelines advocate use of arteriovenous fistula (AVF) over central venous catheter (CVC) for children starting hemodialysis (HD). European data on current practice, determinants of access choice and switches, patient survival, and access to transplantation are limited.

Methods: We included incident patients from 18 European countries who started HD from 2000 to 2013 for whom vascular access type was reported to the ESPN/ERA-EDTA Registry. Data were evaluated using descriptive statistics, logistic and Cox regression models, and cumulative incidence competing risk analysis.

Results: Three hundred ninety-three (55.1%) of 713 children started HD with a CVC and were more often females, younger, had more often an unknown diagnosis, glomerulonephritis, or vasculitis, and lower hemoglobin and height-SDS at HD initiation. AVF patients were 91% less likely to switch to a second access, and two-year patient survival was 99.6% (CVC, 97.2%). Children who started with an AVF were less likely to receive a living donor transplant (adjusted HR, 0.30; 95% CI, 0.16-0.54) and more likely to receive a deceased donor transplant (adjusted HR, 1.50; 95% CI, 1.17-1.93), even after excluding patients who died or were transplanted in the first 6 months.

Conclusions: CVC remains the most frequent type of vascular access in European children commencing HD. Our results suggest that the choice for CVC is influenced by the time of referral, rapid onset of end-stage renal disease, young age, and an expected short time to transplantation. The role of vascular access type on the pattern between living and deceased donation in subsequent transplantation requires further study.

Keywords: Access to transplantation; Arteriovenous fistula; Central venous catheter; End-stage renal disease in children; Renal replacement therapy.

Fig. 1

Vascular access at start of hemodialysis stratified by age group and sex. Patient numbers are presented in each bar. CVC central venous catheter, AVF arteriovenous fistula, y year, m male, f female

Fig. 2

Flow diagram of 713 incident hemodialysis (HD) patients and their different treatment modalities and switch to another vascular access during their follow-up time. Total follow-up time was 1618 patient years (AVF, 769 patient years; CVC, 849 patient years). During follow-up, the overall crude rate of switching was 113 per 1000 patient years at risk (AVF, 31.2 per 1000 patient years; CVC, 187.4 per 1000 patient years). AVF arteriovenous fistula, CVC central venous catheter, PD peritoneal dialysis, TX (LD) transplantation (living donor), TX (DD) transplantation (deceased donor)

Fig. 3

Cumulative incidence curves for a switch of first access or change to PD or b patient mortality stratified by first vascular access. HD hemodialysis, AVF arteriovenous fistula, CVC central venous catheter, PD peritoneal dialysis

Fig. 4

a Cumulative incidence for deceased donor (DD) or living donor (LD) transplantation stratified by first vascular access. b Percentage of patients receiving a kidney from a DD or LD stratified by vascular access type and time period since HD start. HD hemodialysis, AVF arteriovenous fistula, CVC central venous catheter, LD living donor, DD deceased donor