Fistula Use Increasing in U.S. Dialysis Population
Still, approximately 70% of patients initiate dialysis with a catheter.
The United States exhibited “intermediate” fistula and catheter use among 20 countries in 2012 to 2013, and the highest use of grafts.
Arteriovenous fistula (AVF) use increased from 24% in 1997 to 68% in 2013 in the U.S. hemodialysis (HD) population a new study finds. Over the same period, central venous catheter (CVC) use declined from 27% to 15%. These trends continued following the introduction of the prospective payment program for end-stage renal disease (ESRD) in 2011.
“It is clear that a culture devoted to improved vascular access, accelerated through the efforts of the CMS Fistula First Initiative, ESRD Networks, dialysis providers, and the NKF-KDOQI guidelines, has resulted in great gains for this very important facet of U.S. hemodialysis patient care,” stated the research team led by Ronald L. Pisoni, PhD, of the Arbor Research Collaborative for Health in Ann Arbor, MI.
A few challenges remain, however. Among new patients, CVC use at hemodialysis initiation remained high at 70% (other national data report 80%), while AVF use, often considered the best option, remained low. Dialysis facilities in the United States likewise reported longer times to first AVF cannulation. Given the high rates of bacteremia, hospitalization, and mortality associated with CVC, the researchers suggest focusing additional efforts and incentives pre-dialysis to AVF.
For the study, the investigators studied patterns in vascular access use among 3,442 hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) in the U.S., as well as nearly 8,500 patients from 19 other countries. According to results published online ahead of print in the American Journal of Kidney Diseases, the United States exhibited “intermediate” AVF and CVC use among all 20 countries in 2012 to 2013, and the highest use of arteriovenous grafts (AVG).
Investigators also examined vascular access patterns by race. In 2013, AVG use was twice as high in black patients (26%) than others. Lower AVF use in black patients may be explained in part by recent study findings show that African-American males undergoing AV access surgery have significantly smaller median basilic and cephalic vein diameters.
Patient preferences may also play a role in vascular access patterns. The investigators asked patients to complete questionnaires, and while response was low, they received some interesting opinions: fewer female patients preferred an AV access; some patients preferred catheters to avoid large needles, needle sticks, and bleeding; and some were uniformed about the options in vascular access with their relative rates of infection.