Initial Vascular Access Type in Patients with a Failed Renal Transplant

Abstract

Background and objectives Permanent hemodialysis vascular access is crucial for RRT in ESRD patients and patients with failed renal transplants, because central venous catheters are associated with greater risk of infection and mortality than arteriovenous fistulae or arteriovenous grafts. The objective of this study was to determine the types of vascular access used by patients initiating hemodialysis after a failed renal transplant.Design, setting, participants, & measurements Data from the US Renal Data System database on 16,728 patients with a failed renal transplant and 509,643 patients with native kidney failure who initiated dialysis between January 1, 2006, and September 30, 2011 were examined.Results At initiation of dialysis, of patients with a failed transplant, 27.7% (n=4636) used an arteriovenous fistula, 6.9% (n=1146) used an arteriovenous graft, and 65.4% (n=10,946) used a central venous catheter. Conversely, 80.8% (n=411,997) of patients with native kidney failure initiated dialysis with a central venous catheter (P,0.001). Among patients with a failed transplant, predictors of central venous catheter use included women (adjusted odds ratio, 1.75; 95% confidence interval, 1.63 to 1.87), lack of referral to a nephrologist (odds ratio, 2.00; 95% confidence interval, 1.72 to 2.33), diabetes (odds ratio, 1.14; 95% confidence interval, 1.06 to 1.22), peripheral vascular disease (odds ratio, 1.31; 95% confidence interval, 1.16 to 1.48), and being institutionalized (odds ratio, 1.53; 95% confidence interval, 1.23 to 1.89). Factors associated with lower odds of central venous catheter use included older age (odds ratio, 0.85 per 10 years; 95% confidence interval, 0.83 to 0.87), public insurance (odds ratio, 0.74; 95% confidence interval, 0.68 to 0.80), and current employment (odds ratio, 0.87; 95% confidence interval, 0.80 to 0.95).Conclusions Central venous catheters are used in nearly two thirds of failed renal transplant patients. These patients are usually followed closely by transplant physicians before developing ESRD after a failed transplant, but the relatively low prevalence of arteriovenous fistulae/arteriovenous grafts in this group at initiation of dialysis needs to be investigated more thoroughly.

Mortality after Renal Allograft Failure and Return to Dialysis

“…There is a very low incidence of placement of permanent access in patients with failing allograft and widespread use of catheter for initiation of dialysis. Central venous catheters are used in nearly two-thirds of failed renal transplant patients [33]. Reasons for lower rates of creation of AVF are multifactorial such as patient's reluctance to give up on the kidney, physician concern for risk of infection in patients on immunosuppression, and reduction of renal blood flow with high output AVF [33,34].…”

“…Central venous catheters are used in nearly two-thirds of failed renal transplant patients [33]. Reasons for lower rates of creation of AVF are multifactorial such as patient's reluctance to give up on the kidney, physician concern for risk of infection in patients on immunosuppression, and reduction of renal blood flow with high output AVF [33,34]. Attempts should be made to avoid catheter use and initiate dialysis after graft failure with an arteriovenous access.…”

Kidney Transplant Failure

“…Moreover, other studies found that patients with transplant failure are less likely to meet other dialysis clinical practice targets (serum phosphorus, BP, hemoglobin) compared with transplant-naïve patients (8,17,18). Although the rates of surgical vascular access use at hemodialysis initiation were indeed higher among patients with transplant failure (34.6% versus 19.2%), rates of pre-emptive AVF/AVG placement among patients with transplant failure who started hemodialysis with a CVC were slightly lower (21% of CVCs) compared with transplant-naïve patients (23% of CVCs), suggesting that a larger proportion of patients with transplant failure may not have had any predialysis access planning (15).…”

“…Unlike a significant proportion of transplant-naïve hemodialysis patients, patients with transplant failure should be well known to the transplant nephrology care team. Moreover, as a group, these patients have fewer comorbidities than their transplantnaïve counterparts, factors that Chan et al and others have found to be more predictive of AVF/AVG use at hemodialysis initiation (15,19). Surprisingly, Chan et al reported that .31% of patients with transplant failure were classified as having either no nephrology referral or a referral of #1 year before dialysis initiation.…”

“…In this issue of CJASN, Chan et al use US Renal Data System (USRDS) data to examine the distribution of vascular access type at dialysis initiation comparing a cohort of 16,728 patients who initiated dialysis after transplant failure versus 509,643 transplant-naïve incident dialysis patients (15). The authors found that 34.6% of patients with transplant failure initiated hemodialysis with a surgical access (arteriovenous fistula [AVF] or arteriovenous graft [AVG]) compared with 19.2% of patients in the transplant-naïve groups, whereas the remainder of patients in both groups started dialysis with a central venous catheter (CVC).…”