National Profile of Practice Patterns for Hemodialysis Vascular Access in the United States

Reddan, Donal; Klassen, Preston S.; Frankenfield, Diane L.; Szczech, Lynda A.; Schwab, Steve J.; Coladonato, Joseph A.; Rocco, Michael V.; Lowrie, Edmund G.; Owen, William F.

doi:10.1097/01.asn.0000022422.79790.a8

Cited by 118 publications

(123 citation statements)

References 30 publications

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“…This is similar to regional differences in Australia (23) and the United States (30). These differences in practice patterns are likely multifactorial and cannot be described using these data.…”

Section: Discussionsupporting

confidence: 74%

Increased Hemodialysis Catheter Use in Canada and Associated Mortality Risk

Moist

Trpeski

et al. 2008

Clinical Journal of the American Society of Nephrology

136

117

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.6% to 18.6%, and grafts remained between 2.1% to 2.6%. Prevalent catheter use increased from 41.8% to 51.7%, and fistulas and grafts decreased from 46.8% to 41.6% and 11.4% to 6.7%, respectively. There was significant variation in incident and prevalent fistulae use among the provinces. Adjustment for differences in patient characteristics did not change these trends. Incident catheter use was associated with a 6 times greater risk of death compared with fistula or graft use combined.Conclusions: In Canada there has been a decrease in fistulae and grafts with a subsequent increase in catheters that is not explained by changes in patient characteristics. Vascular access use varied by province, suggesting differences in practice patterns. Because incident catheter use was associated with increased mortality, urgent measures are needed to develop strategies to decrease catheter use.

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Section: Discussionsupporting

confidence: 74%

Increased Hemodialysis Catheter Use in Canada and Associated Mortality Risk

Moist

Trpeski

et al. 2008

Clinical Journal of the American Society of Nephrology

136

117

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“…After adjustment for the baseline factors, the highdose group had a 3% lower rate for the composite of first infectionrelated hospitalization or all-cause death (95% CI, Ϫ9% to ϩ14%; P ϭ 0.60) than the standard-dose group, and the high-flux group had an 9% lower rate (95% CI, Ϫ3% to ϩ19%; P ϭ 0.14) than the low-flux group. 20%) (22)(23)(24), the burden of catheter-associated infection is likely much higher in the general US dialysis population.…”

Section: Discussionmentioning

confidence: 99%

Impact of Dialysis Dose and Membrane on Infection-Related Hospitalization and Death

Allon¹,

Depner

Radeva

et al. 2003

Journal of the American Society of Nephrology

196

136

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Abstract. Infection is the second most common cause of death among hemodialysis patients. A predefined secondary aim of the HEMO study was to determine if dialysis dose or flux reduced infection-related deaths or hospitalizations. The effects of dialysis dose, dialysis membrane, and other clinical parameters on infection-related deaths and first infection-related hospitalizations were analyzed using Cox regression analysis. Among the 1846 randomized patients (mean age, 58 yr; 56% female; 63% black; 45% with diabetes), there were 871 deaths, of which 201 (23%) were due to infection. There were 1698 infection-related hospitalizations, yielding a 35% annual rate. . The first infection-related hospitalization was related to the vascular access in 21% of the cases, and non-access-related in 79%. Catheters were present in 32% of all study patients admitted with access-related infection, even though catheters represented only 7.6% of vascular accesses in the study. In conclusion, infection accounted for almost one fourth of deaths. Infection-related deaths were not reduced by higher dose or by high flux dialyzers. In this prospective study, most infection-related hospitalizations were not attributed to vascular access. However, the frequency of accessrelated, infection-related hospitalizations was disproportionately higher among patients with catheters compared with grafts or fistulas.Infection is the second most common cause of death (after cardiovascular disease) among hemodialysis patients (1,2) and is a frequent cause of hospitalization (3). Mortality due to sepsis occurs about 250-fold more commonly among hemodialysis patients than among the general population (4). There is limited literature analyzing the type and frequency of serious infections among hemodialysis patients. Most reported studies are retrospective and have identified diabetes, older age, comorbidity, hypoalbuminemia, and the use of a temporary dialysis catheter as the major, independent risk factors for serious infections (1,3-7).Observational studies have suggested that a higher dialysis dose and use of a high-flux membrane may each decrease the likelihood of infectious events (1,8), but these potential benefits have not been evaluated in randomized studies. The HEMO Study was a large, prospective, multicenter study in which chronic hemodialysis patients were randomized to receive either standard-dose or high-dose dialysis and to use high-flux or low-flux dialyzers, and clinical outcomes tracked prospectively (9). A predefined secondary aim of the study was to determine whether dialysis dose (clearance of small molecules) or membrane flux (clearance of larger molecules) affected infectionrelated deaths or hospitalizations.The present report (1) evaluates the frequency and specific etiologies of infection-related deaths and hospitalizations in this defined patient population (2), assesses whether a higher Kt/V or high-flux dialyzer decreased the likelihood of serious infections, and (3) determines what other baseline clinical factors affect infect...

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“…Hospitalizations were reported as cardiovascular, vascular access related (14,15), or other. Although hospitalizations were not centrally adjudicated, categories of hospitalization were captured and reported by the attending physicians.…”

Section: Study Rationale Design Monitoring and Interventionsmentioning

confidence: 99%

Intradialytic Blood Volume Monitoring in Ambulatory Hemodialysis Patients

Reddan

Szczech

Hasselblad

et al. 2005

Journal of the American Society of Nephrology

Self Cite

183

168

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Complications related to inadequate volume management are common during hemodialysis. This trial tested the hypothesis that availability of an intradialytic blood volume monitoring (IBVM) device improves fluid removal, reducing morbidity. A six-center, randomized trial with 6 mo of intervention comparing IBVM using Crit-Line versus conventional clinical monitoring was conducted. The average rate of non-access-related hospitalizations was compared across treatment groups using Poisson regression. Mortality analysis used the Kaplan Meier method. A total of 227 patients were randomized to Crit-Line, and 216 were randomized to conventional monitoring. Both groups had similar baseline characteristics. During the study, no differences in weight, BP, or number of dialysis-related complications were observed. There were 120 and 81 non-access-related hospitalizations in the Crit-Line and conventional monitoring groups. The adjusted risk ratio for non-access-related and access-related hospitalization was 1.61 (95% confidence interval 1.15 to 2.25; P ‫؍‬ 0.01) and 1.52 (95% confidence interval 1.02 to 2.28; P ‫؍‬ 0.04) for the Crit-Line monitoring group. Mortality was 8.7% in the Crit-Line monitoring group and 3.3% in the conventional group (P ‫؍‬ 0.021). Standardized mortality ratios comparing the Crit-Line and conventional monitoring groups to the prevalent hemodialysis population were 0.77 (NS) and 0.26 (P < 0.001). Hospitalization rates were 1.51 and 1.03 events/yr in the Crit-Line and standard monitoring groups, compared with 2.01 for the prevalent hemodialysis population. IBVM was associated with higher nonvascular and vascular access-related hospitalizations and mortality compared with conventional monitoring. The atypically low hospitalization and mortality rates for the conventional monitoring group suggest that these findings should be generalized to the US hemodialysis population with caution.

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National Profile of Practice Patterns for Hemodialysis Vascular Access in the United States

Cited by 118 publications

References 30 publications

Increased Hemodialysis Catheter Use in Canada and Associated Mortality Risk

Increased Hemodialysis Catheter Use in Canada and Associated Mortality Risk

Impact of Dialysis Dose and Membrane on Infection-Related Hospitalization and Death

Intradialytic Blood Volume Monitoring in Ambulatory Hemodialysis Patients

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