Document Detail

Change in vascular access and mortality in maintenance hemodialysis patients.
MedLine Citation:
PMID:  19748717     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: We hypothesized that a change from central venous catheters to a fistula or graft would improve short-term mortality risk in maintenance hemodialysis patients. DESIGN: Prospective observational study. SETTING & PARTICIPANTS: All maintenance in-center hemodialysis patients treated in Fresenius Medical Care, North America legacy facilities alive on January 1, 2007 with baseline laboratory data from December 2006. PREDICTOR: Access type (fistula, catheter, or graft), determined on December 31, 2006, and monthly thereafter. Conversion from a catheter to a fistula or graft during the 4-month period from January 1 to April 30, 2007. OUTCOME: Mortality was tracked from May 1, 2007, to December 31, 2007. Standard and time-dependent Cox models were used to determine hazard risks (HRs) of death with and without adjustment for case-mix and laboratory values. RESULTS: At baseline, 79,545 patients had 43% fistulas, 29% catheters, and 27% grafts. Mean age was 62 +/- 15 years, 54% were men, 51% were white, and 53% had diabetes. Compared with fistulas, unadjusted HRs of death were higher for grafts (1.22) and catheters (1.76; P < 0.001). In adjusted models, overall risk for grafts was decreased to 1.05 (95% limits, 1.003-1.100; P < 0.05) and approached that for fistulas consistently across multiple strata. Compared with patients who continued using a catheter, those who converted to either a graft or fistula had an HR of 0.69, whereas those who converted from a graft or fistula to a catheter had increased HRs to 2.12 (both P < 0.001). Similar trends were observed in the subset of incident patients (vintage < 90 days at study onset). LIMITATIONS: Observational design with residual confounding from unmeasured patient, facility, and treatment-related factors. CONCLUSIONS: Catheters have the worst associated mortality risk. Changing from a catheter to a fistula or graft is associated with significantly improved survival. The risk for grafts approached that of fistulas, providing an alternative to prolonged catheter exposure and potentially less hazardous "bridge" toward a fistula.
Eduardo Lacson; Weiling Wang; J Michael Lazarus; Raymond M Hakim
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Publication Detail:
Type:  Journal Article     Date:  2009-09-12
Journal Detail:
Title:  American journal of kidney diseases : the official journal of the National Kidney Foundation     Volume:  54     ISSN:  1523-6838     ISO Abbreviation:  Am. J. Kidney Dis.     Publication Date:  2009 Nov 
Date Detail:
Created Date:  2009-10-26     Completed Date:  2009-11-16     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  8110075     Medline TA:  Am J Kidney Dis     Country:  United States    
Other Details:
Languages:  eng     Pagination:  912-21     Citation Subset:  IM    
Fresenius Medical Care-North America, Waltham, MA 02451-1457, USA.
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MeSH Terms
Arteriovenous Shunt, Surgical*
Catheterization, Central Venous*
Catheters, Indwelling*
Middle Aged
Prospective Studies
Renal Dialysis / methods*,  mortality*

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