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Comment & Response
January 2016

Major Effect of the Syndrome of Rapid-Onset End-Stage Renal Disease on the Use of Arteriovenous Fistulas: High Rates of Initiation of Hemodialysis With Hemodialysis Catheter in the United States

Author Affiliations
  • 1Mayo Clinic College of Medicine, Rochester, Minnesota
  • 2Department of Nephrology, Mayo Clinic Health System, Eau Claire, Wisconsin
JAMA Surg. 2016;151(1):96. doi:10.1001/jamasurg.2015.2430

To the Editor Whereas classic teaching highlights reduced infection risk, fewer hospitalizations, and lower total costs associated with hemodialysis (HD) that is initiated via arteriovenous fistula (AVF) vs hemodialysis catheter (HC), and whereas the National Kidney Foundation–Kidney Disease Outcomes Quality Initiative1 first published practice guidelines regarding permanent HD access creation and maintenance in 1997, targeting a 50% or greater incidence rate for AVF, Malas et al2 have demonstrated in a retrospective analysis of 510 000 patients with end-stage renal disease (ESRD) in the US Renal Data System database that 82.6% of these patients initiated HD via HC, 14.0% via AVF, and 3.4% via arteriovenous graft. Arteriovenous fistula use increased only minimally, from 12.2% in 2006 to 15.0% in 2010.2 Furthermore, patients initiating HD with AVF had 35% lower mortality than those initiating HD with HC (adjusted hazard ratio, 0.65; 95% CI, 0.64-0.66; P < .001).2 As a consequence, survival at 1 year was 78% in the HC group compared with 84% for the arteriovenous graft group and 89% for the AVF group (Wilcoxon P < .001).2 Arteriovenous fistula use was associated with a 38% lower hazard of cardiovascular mortality (adjusted hazard ratio, 0.62; 95% CI, 0.61-0.64; P < .001) and with a 44% lower hazard of sepsis-related mortality (adjusted hazard ratio, 0.56; 95% CI, 0.53-0.59; P < .001).2