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Original Investigation
May 2015

Trends in Incident Hemodialysis Access and Mortality

Author Affiliations
  • 1Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
  • 2Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
  • 3The Health System, University of California at Davis, Sacramento
  • 4Former Editor, JAMA Surgery
JAMA Surg. 2015;150(5):441-448. doi:10.1001/jamasurg.2014.3484
Abstract

Importance  Based on evidence of survival benefit when initiating hemodialysis (HD) via arteriovenous fistula (AVF) or arteriovenous graft (AVG) vs hemodialysis catheter (HC), the National Kidney Foundation–Kidney Disease Outcomes Quality Initiative published practice guidelines in 1997 recommending 50% or greater AVF rates in incident HD patients. A decade after, lapses exist and the impact on HD outcomes is uncertain.

Objective  To assess the achievement of the practice goals for incident vascular access and the effects on HD outcomes.

Design, Setting, and Participants  This retrospective cohort study was conducted using the US Renal Data System. All patients with end-stage renal disease in the United States without prior renal replacement therapy who had incident vascular access for HD created between January 1, 2006, and December 31, 2010 (N = 510 000) were included.

Main Outcomes and Measures  Incident vascular access use rates and mortality. Relative mortality was quantified using multivariable Cox proportional hazard models. Coarsened exact matching and propensity score–matching techniques were used to better account for confounding by indication.

Results  Of 510 000 patients included in this study, 82.6% initiated HD via HC, 14.0% via AVF, and 3.4% via AVG. Arteriovenous fistula use increased only minimally, from 12.2% in 2006 to 15.0% in 2010. Patients initiating HD with AVF had 35% lower mortality than those with HC (adjusted hazard ratio, 0.65; 95% CI, 0.64-0.66; P < .001). Those initiating HD with AVF had 23% lower mortality than those initiating with an HC while awaiting maturation of an AVF (adjusted hazard ratio, 0.77; 95% CI, 0.76-0.79; P < .001).

Conclusions and Relevance  Current incident AVF practice falls exceedingly short years after recommendations were made in 1997. The impact of this shortcoming on mortality for patients with end-stage renal disease is enormous. Functioning permanent access at initiation of HD confers lower mortality even compared with patients temporized with an HC while awaiting maturation of permanent access. A change of current policies and structured multidisciplinary efforts are required to establish matured fistulae prior to HD to ameliorate this deficit in delivering care.

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