Dataset Information

Vascular access placement and mortality in elderly incident hemodialysis patients.

ABSTRACT: BACKGROUND:Arteriovenous fistulas (AVFs) are the preferred vascular access type in most hemodialysis patients. However, the optimal vascular access type in octogenarians and older (?80?years) hemodialysis patients remains widely debated given their limited life expectancy and lower AVF maturation rates. METHODS:Among incident hemodialysis patients receiving care in a large national dialysis organization during 2007-2011, we examined patterns of vascular access type conversion in 1 year following dialysis initiation in patients <80 versus ?80 years of age. Among a subcohort of patients ?80?years of age, we examined the association between vascular access type conversion and mortality using multivariable survival models. RESULTS:In the overall cohort of 100?804 patients, the prevalence of AVF/arteriovenous graft (AVG) as the primary vascular access type increased during the first year of hemodialysis, but plateaued thereafter. Among 8356 patients ?80?years of age and treated for >1 year, those with initial AVF/AVG use and placement of AVF from a central venous catheter (CVC) had lower mortality compared with patients with persistent CVC use. When the reference group was changed to patients who had AVF placement from a CVC in the first year of dialysis, those with initial AVF use had similar mortality. A longer duration of CVC use was associated with incrementally worse survival. CONCLUSIONS:Among incident hemodialysis patients ?80?years of age, placement of an AVF from a CVC within the first year of dialysis had similar mortality compared with initial AVF use. Our data suggest that initial CVC use with later placement of an AVF may be an acceptable option among elderly hemodialysis patients.

SUBMITTER: Ko GJ

PROVIDER: S-EPMC7057539 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Vascular access placement and mortality in elderly incident hemodialysis patients.

Ko Gang Jee GJ Rhee Connie M CM Obi Yoshitsugu Y Chang Tae Ik TI Soohoo Melissa M Kim Tae Woo TW Kovesdy Csaba P CP Streja Elani E Kalantar-Zadeh Kamyar K

Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 20200301 3

<h4>Background</h4>Arteriovenous fistulas (AVFs) are the preferred vascular access type in most hemodialysis patients. However, the optimal vascular access type in octogenarians and older (≥80 years) hemodialysis patients remains widely debated given their limited life expectancy and lower AVF maturation rates.<h4>Methods</h4>Among incident hemodialysis patients receiving care in a large national dialysis organization during 2007-2011, we examined patterns of vascular access type conversion in 1 ...[more]

PMID: 30107612

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Project description:RATIONALE & OBJECTIVE:National vascular access guidelines recommend placement of arteriovenous fistulas (AVFs) over grafts (AVGs) in hemodialysis patients, but have not been comprehensively assessed in the elderly. We evaluated clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation. STUDY DESIGN:Retrospective cohort study using national administrative data. SETTINGS & PARTCIPANTS:Claims data from the US Renal Data System of 9,458 US patients 67 years and older who initiated hemodialysis therapy from July 1, 2010, to June 30, 2011, with a catheter and received an AVF (n=7,433) or AVG (n=2,025) within the ensuing 6 months. PREDICTOR:Arteriovenous access subtype, AVF or AVG. OUTCOMES:Successful use of vascular access, interventions to make vascular access functional, duration of catheter dependence before successful use of vascular access, frequency of interventions, and abandonment after successful use of vascular access. ANALYTICAL APPROACH:Multivariable logistic regression analysis was used to compare the need for intervention before successful use of AVFs and AVGs, and negative bionomial regression was used to calculate the frequency of intervention after successful use of vascular access. RESULTS:Unsuccessful use of vascular access within 6 months of creation was higher for AVFs versus AVGs (51% vs 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99). Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs 23%; OR, 2.66; 95% CI, 2.26-3.12). AVFs had a lower 1-year abandonment rate after successful use compared with AVGs (OR, 0.71; 95% CI, 0.62-0.83) and required one-fourth fewer interventions after successful use (relative risk, 0.75; 95% CI, 0.69-0.81). Patients receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs 1 month; P<0.001). LIMITATIONS:Residual confounding due to vascular access choice, restriction to an elderly population, and 1-year follow-up period. CONCLUSIONS:In elderly hemodialysis patients initiating hemodialysis therapy with a catheter, the optimal vascular access selection depends on tradeoffs between shorter catheter dependence and less frequent interventions to make the vascular access (AVG) functional versus longer access patency and fewer interventions after successful use of the vascular access (AVF).

Project description:Rationale & objectiveAs the proportion of arteriovenous fistulas (AVFs) compared with arteriovenous grafts (AVGs) in the United States has increased, there has been a concurrent increase in interventions. We explored AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis.Study designObservational cohort study.Setting & participantsPatients initiating hemodialysis from July 1, 2012, to December 31, 2014, and having a first-time AVF or AVG placement between dialysis initiation and 1 year (N = 73,027), identified using the US Renal Data System (USRDS).PredictorsPatient characteristics.OutcomeSuccessful AVF/AVG use and intervention procedure burden.Analytical approachFor each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modeling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase.ResultsDuring the maturation phase, 13,989 of 57,275 patients (24.4%) in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person. In the AVG group 2,904 of 15,572 patients (18.4%) required intervention during maturation, with therapeutic interventional requirements of 0.28 per person. During the maintenance phase, in the AVF group 12,732 of 32,115 patients (39.6%) required intervention, with a therapeutic intervention rate of 0.93 per person-year. During maintenance phase, in the AVG group 5,928 of 10,271 patients (57.7%) required intervention, with a therapeutic intervention rate of 1.87 per person-year. For both phases, the intervention rates for AVF tended to be higher on the East Coast while those for AVG were more uniform geographically.LimitationsThis study relies on administrative data, with monthly recording of access use.ConclusionsDuring maturation, interventions for both AVFs and AVGs were relatively common. Once successfully matured, AVFs had lower maintenance interventional requirements. During the maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.

Project description:In the general population, low serum magnesium levels are associated with poor outcomes and death. While limited data suggest that low baseline magnesium levels may be associated with higher mortality in hemodialysis (HD) patients, the impact of changes in magnesium levels over time is unknown.We examined the association of time-varying serum magnesium levels with all-cause mortality using multivariable time-varying survival models adjusted for clinical characteristics and other time-varying laboratory measures.9,359 maintenance HD patients treated in a large dialysis organization between 2007 and 2011.Time-varying serum magnesium levels across 5 magnesium increments (<1.8, 1.8-<2.0, 2.0-<2.2, 2.2-<2.4, and ?2.4mg/dL).All-cause mortality.2,636 individuals died over 5 years. Time-varying serum magnesium levels < 2.0mg/dL were associated with higher mortality after adjustment for demographics and comorbid conditions, including hypertension, diabetes, and malignancies (reference: magnesium, 2.2-<2.4mg/dL): adjusted HRs for serum magnesium level < 1.8 and 1.8 to <2.0mg/dL were 1.39 (95% CI, 1.23-1.58; P<0.001) and 1.20 (95% CI, 1.06-1.36; P=0.004), respectively. Some associations were attenuated to the null after incremental adjustment for laboratory test results, particularly serum albumin. However, among patients with serum albumin measurements, low albumin level (<3.5g/dL) and magnesium level < 2.0mg/dL were associated with an additional death risk (adjusted HR, 1.17; 95% CI, 1.05-1.31; P=0.004), whereas patients with high serum albumin levels (?3.5g/dL) exhibited low death risk (adjusted HRs of 0.53 and 0.53 [P?0.001] for magnesium < 2.0 and ?2.0mg/dL, respectively; reference: albumin < 3.5g/dL and magnesium ? 2.0mg/dL).Causality cannot be determined, and residual confounding cannot be excluded given the observational study design.Lower serum magnesium levels are associated with higher mortality in HD patients, including those with hypoalbuminemia. Interventional studies are warranted to examine whether correction of hypomagnesemia ameliorates adverse outcomes in this population.

Project description:BackgroundPre-ESKD Kidney Disease Education (KDE) has been shown to improve multiple CKD outcomes, but its effect on vascular access outcomes is not well studied. In 2010, Medicare launched KDE reimbursements policy for patients with advanced CKD.MethodsIn this retrospective USRDS analysis, we identified all adult patients on incident hemodialysis with ≥6 months of pre-ESKD Medicare coverage during the first 5 years of CMS-KDE policy and divided them into CMS-KDE services recipients (KDE cohort) and nonrecipients (non-KDE cohort). The primary outcome was incident arteriovenous fistula (AVF) and the composite of incident AVF or arteriovenous graft (AVG) utilization. Secondary outcomes were central venous catheter (CVC) with maturing AVF/AVG and pure CVC utilizations. Step-wise multivariate analyses were performed in four progressive models (model 1, KDE alone; model 2, multivariate model encompassing model 1 with sociodemographics; model 3, model 2 with comorbidity and functional status; and model 4, model 3 with pre-ESKD nephrology care).ResultsOf the 211,990 qualifying patients on incident hemodialysis during the study period, 2887 (1%) received KDE services before dialysis initiation. The rates of incident AVF and composite AVF/AVG were more than double (30% and 35%, respectively, compared with 14% and 17%), and pure catheter use about a third lower (40% compared with 65%) in the KDE cohort compared with the non-KDE cohort. The maximally adjusted odds ratios in model 4 for study outcomes were incident AVF use, 1.78, 99% confidence interval, 1.55 to 2.05; incident AVF/AVG use, 1.78, 99% confidence interval, 1.56 to 2.03; incident CVC with maturing AVF/AVG, 1.69, 99% confidence interval, 1.44 to 1.97; and pure CVC without any AVF/AVG, 0.51, 99% confidence interval, 0.45 to 0.58. The benefits of the KDE service were maintained even after accounting for the presence, duration, and facility of ESKD care.ConclusionThe occurrence of pre-ESRD KDE service is associated with significantly improved incident vascular access outcomes. Targeted studies are needed to examine the effect of KDE on patient engagement and self-efficacy as a cause for improvement in vascular access outcomes.

Project description:Few reports have shown an association between access type and inflammatory marker levels in a longitudinal cohort. We investigated the role of access type on serial levels of inflammatory markers and the role of inflammatory markers in mediating the association of access type and risk of mortality in a prospective study of incident dialysis patients.Cohort study, post hoc analysis of the CHOICE (Choices for Healthy Outcomes in Caring for ESRD) Study.In 583 participants, inflammation was assessed by measuring serum C-reactive protein (CRP) and interleukin 6 (IL-6) after access placement and at multiple times during 3 years' follow-up. Type of access was categorized as central venous catheter (CVC), arteriovenous graft (AVG), and arteriovenous fistula (AVF), and changes over time were recorded.Access type, age, sex, race, body mass index, diabetes, cardiovascular disease, and serum albumin level.CRP level, IL-6 level, and mortality.We used mixed-effects pattern mixture models to study the association between access type and repeated measurements of inflammation and survival analysis to investigate the association of access type and mortality, adjusting for predictors.In a mixed-effects pattern mixture model, compared with AVFs, the presence of CVCs and AVGs was associated with 62% (P=0.02) and 30% (P=0.05) increases in average CRP levels, respectively. A Cox proportional hazards model yielded nonsignificant associations of CVC and AVG use (vs AVFs) with risk of mortality when adjusted for inflammatory marker levels. Higher CRP levels were associated with increased risk of CVC failure than lower CRP levels.CRP and IL-6 measurements not performed for all hemodialysis patients.CVCs, compared with AVFs, are associated with a greater state of inflammation in incident hemodialysis patients, and the association of catheter use and mortality may be mediated by access-induced inflammation. Our findings support recommendations for the early removal or avoidance of CVC placements.

Dataset Information

Vascular access placement and mortality in elderly incident hemodialysis patients.

Publications

Vascular access placement and mortality in elderly incident hemodialysis patients.

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