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Dialysis outcomes with graft vs. fistula vary by race, ethnicity in older patients
Among older patients undergoing hemodialysis, outcomes achieved with fistulas vs. grafts vary significantly by race/ethnicity, according to recent findings.
In the study, researchers reviewed Medicare outpatient, inpatient and carrier files from 2006 to 2011 for beneficiaries who met the following criteria: aged 66 years or older, qualification for Medicare by age only, dialysis-dependent at the time of index fistula/graft creation and continuous enrollment in Medicare 12 months before and after fistula/graft creation.
The primary outcomes were early vascular access failure and 12-month failure-free survival, defined as the variation in the difference between fistula and graft in nonwhite vs. white races/ethnicities.
Failure disparities
The researchers found that a smaller proportion of black patients (65.9%; P < .001) and Asian patients (71.4%; P < .001) were treated with fistula creation vs. white patients (78%), with no disparity between Hispanic and white patients (78.7%; P = .59) The following rates of early failure post-graft vs. post-fistula were observed: white patients, 34.9% vs. 43.5% (P < .001); black patients, 32.9% vs. 49.1% (P < .001); Asian patients, 30.8% vs. 40.5% (P < .014); and Hispanic patients, 35.2% vs. 43.2% (P = .005).
Black patients had a larger disparity in early failure after fistula vs. graft compared with the disparity in white patients (P < .001).
The overall mortality rate during the 12 months after the index vascular access procedure was 28.7% (n = 4,707). The unadjusted 12-month mortality rates were as follows: white patients, 31.3%; black patients, 25%; Asian patients, 23.3%; and Hispanic patients, 23.3%. The unadjusted 12-month mortality rate was higher in grafts vs. fistulas for white and black patients, with no difference for Asian or Hispanic patients. After adjustment for demographics and comorbidities, the disparity between grafts and fistulas ceased to be significant in black patients. The fully adjusted model revealed a higher mortality rate in grafts vs. fistulas for white patients (32.4% vs. 30%; P = .03). Among black, Asian and Hispanic patients, no disparity in mortality was seen in grafts vs. fistulas.
Failure-free survival
The unadjusted rates of 12-month failure-free survival were significantly higher for grafts vs. fistula. There were no major changes in the absolute or relative 12-month failure-free survival in the intermediate models.
In the fully adjusted model, the following rates of 12-month failure-free survival after graft vs. fistula were reported: white patients, 41.9% vs. 38.9% (P = .008); black patients, 48.5% vs. 37.3% (P < .001); Asian patients, 51.6% vs. 45.2% (P = .98); and Hispanic patients, 51.9% vs. 42.2% (P < .001). Compared with white patients, Hispanic patients (P = .02) and black patients (P < .001) had a greater difference in 12-month failure-free survival after graft vs. fistula, according to the researchers.
“The 12-month outcomes in 16,402 patients undergoing placement of arteriovenous fistula and [arteriovenous] graft were inferior in black and Hispanic patients compared with white patients,” the researchers wrote. “This study suggests that further investigation is necessary to understand why blacks and Hispanics have inferior outcomes compared with whites after [arteriovenous] access placement.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.