Background
Hemodialysis(HD) access is considered a critical and actionable determinant of morbidity, with a growing literature suggesting that initial HD access type is an important marker of long term outcomes. Accordingly, we examined HD access during the incident dialysis period, focusing on infection risk and successful fistula creation over the first dialysis year.
Study Design
Longitudinal cohort
Setting & Participants
All United States adults admitted to Fresenius Medical Care North America facilities within 15 days of first maintenance dialysis session between January 1 and December 31, 2007.
Predictor
Vascular access type at HD initiation
Outcomes
Vascular access type at 90 days and at the end of the first year on HD, bloodstream infection within the first year by access type, and catheter complication rate.
Results
Amongst the 25,003 incident dialysis patients studied, 19,622(78.5%) initiated dialysis with a catheter, 4,151(16.6%) with a fistula, and 1,230(4.9%) with a graft. At 90 days, 14,105(69.7%) had a catheter, 4432(21.9%) patients had a fistula, and 1705(8.4%) had a graft. Functioning fistulas and grafts at dialysis initiation had first year failure rates of 10% and 15%, respectively. Grafts were seldom replaced by fistulas (3%), while 7,064 (47.6%) of all patients who initiated with a catheter alone still had only a catheter at 1 year. Overall, 3,327 (13.3%) patients had at least one positive blood culture during follow-up, with the risk being similar between fistula and graft groups, but approximately 3-fold higher in patients with a catheter (p<0.001 for either comparison). Nearly one in three catheters (32.5%) will require TPA use by median time of 41 days, with 59% requiring more than one TPA administration.
Limitations
Potential underestimation of bacteremia because follow-up blood culture results did not include samples sent to local laboratories.
Conclusions
Among a large and representative population of incident US dialysis patients, catheter use remains very high over the first year of hemodialysis care, and is associated with high mechanical complication and blood stream infection rates.