Central venous catheter practice patterns for dialysis access vary by patient sex, race
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Racial and sex differences exist for patients on hemodialysis regarding time spent on a central venous catheter and the likelihood of transferring to permanent access, according to study results.
“Of incident hemodialysis patients in the United States, 80% start hemodialysis on a central venous catheter (CVC),” Shipra Arya, MD, FACS, of Stanford University School of Medicine, and colleagues wrote. “Despite a national push toward arteriovenous fistula and arteriovenous graft use, little is known about the characteristics and natural history of patients who start hemodialysis on a CVC.”
Using data from the US Renal Data System, researchers identified 74,194 Medicare-eligible patients who initiated dialysis between July 1, 2010 (the date when CMS began requiring dialysis claim bills to include type of vascular access being used) and Dec. 31, 2013.
While the mean time spent on CVC for the entire cohort was 220.1 days, researchers observed women spent a longer time on CVC than men (mean 229.5 days vs. 211.5 days) and that black (mean 243.2 days) and Hispanic patients (mean 237.6 days) spent a longer time on CVC compared with white patients (mean 209.3 days). It was further determined that black women spent the longest time on CVC, while white men spent the least amount of time (245.8 vs. 200.8 days).
At 1 year following dialysis initiation, 32.7% of all patients transitioned to an arteriovenous fistula; 10.8% transitioned to an arteriovenous graft; 32.1% stayed on a CVC and 24.5% died. Researchers found women and black patients were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Mortality at 1 year was higher in white patients.
Researchers noted risk factors for transition to arteriovenous graft rather than arteriovenous fistula included advancing age and hospitalization within the past year. In addition, patients who received early nephrology care (before ESKD) had a higher likelihood of transition to permanent access with either fistula or graft.
Furthermore, researchers argued that while biologic reasons may partially explain these differences (with previous studies reporting more difficulty establishing successful access in black patients and women), “the longer CVC time may also reflect system-related factors such as poor access to care.”
They concluded, “Because prolonged catheter use [ 90 days] is associated with decreased survival and failure of future access modalities, there is an urgent need for clinicians and policymakers to shift focus to minimizing catheter use for patients starting hemodialysis through CVC.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Silvi Shah, MD, MS, FACP, FASN
Although arteriovenous access confers survival benefits over CVC in hemodialysis patients, about 80% of patients initiate dialysis with CVC. Due to survival advantage with the use of an arteriovenous access, there are efforts nationwide that limit the use of CVC. The present study examines the racial and sex disparities in the use of CVC and dialysis access. The authors used the U.S. Renal Data System to evaluate the natural history of CVC use and transition to the use of arteriovenous graft or fistula among incident hemodialysis Medicare patients aged 67 years and more. At 1 year after initialing hemodialysis with CVC, about 33% of the patients stayed on a CVC.
Women spent a longer time on CVC as compared to men, had a lower likelihood to transition to an arteriovenous fistula, but a higher likelihood to transition to graft. Similarly, minorities as compared to white patients spend longer time on CVC, but were more likely to transition to a permanent access. These significant study findings highlight the differences across sex and race that continue to persist in the use of permanent vascular access among patients undergoing hemodialysis. The reasons for these hemodialysis vascular access disparities are still largely unknown but could be related to the biological factors, system factors like access of care, and the physician and patient bias. Women are shown to have lower rates of fistula maturation and later referrals for dialysis initiation as compared to men.
The study highlights the need for improvement in the process of care factors in clinical care of ESKD patients. Future steps remain to better understand the causes behind these differences and formulate nationwide policies to improve vascular access care among women and minorities.
University of Cincinnati
Cincinnati
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