Fistula yields lowest infection rates, but most patients still initiate hemodialysis with catheter
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Study findings indicated that although most patients who had insurance before developing end-stage renal disease initiate hemodialysis with a central venous catheter, use of fistula for vascular access demonstrated the lowest risk for subsequent bloodstream infections.
“For the majority of patients with CKD, having comprehensive health insurance coverage is particularly important and is believed to facilitate early referral to nephrology care and the opportunity for timely placement of a fistula,” Sophia V. Kazakova, MD, MPH, PhD, of the division of health care quality promotion in the National Center for Emerging and Zoonotic Infectious Diseases at the CDC, and colleagues, wrote.
The researchers contended that the initiation of hemodialysis with a fistula has repeatedly been shown to lead to better outcomes than initiation with a central venous catheter (CVC), the latter of which has been linked to septicemia and high mortality rates.
“As a result,” the researchers added, “guidelines from the Centers for Disease Control and Prevention and the clinical practice guidelines for vascular access of the National Kidney Foundation’s Dialysis Outcomes Quality Initiative recommend the use of arteriovenous accesses designed for long-term use, such as fistulas and grafts.”
To examine how early use of fistulas may help prevent severe bloodstream infections among older patients who initiate the treatment, researchers estimated the risk for infection with each vascular access type in 2,352 patients who had complete pre-ESRD Medicare fee-for-service coverage for 2 years (79.5% initiated with CVC; 3.3% with graft; 17.2% with fistula).
They found that, compared with CVC or graft, incident fistula use was associated with a 61% lower risk for bloodstream infection (HR = 0.39).
Furthermore, during the first year of treatment, they determined incident hospitalization rates for bloodstream infections to be 1.3 per 1,000 person-days for patients initiating with CVC, 0.8 for those initiating with graft and 0.3 for those initiating with fistula.
These findings led the researchers to suggest that barriers exist to pre-dialysis care for patients on fee-for-service Medicare coverage. Writing that “previous studies linked incident CVC use with late nephrologist referral and lack of pre-ESRD nephrology care,” they cited one study in particular that found “33% of new patients with ESRD, the majority of whom were Medicare beneficiaries, received no prior nephrology care.”
According to the researchers, other factors may limit fistula use, including patient denial of the severity of CKD, poor patient education on vascular access, lack of coordinated multidisciplinary care with surgeons and radiologists, and poor patient follow-up.
Therefore, they concluded that “[t]he challenge of achieving early fistula use and reducing CVC prevalence likely requires a combination of strategies, beyond pre-ESRD insurance, to successfully reach and prepare patients for dialysis and coordinate CKD care with future dialysis needs.”
According to David Packer, DO, and James S. Kaufman, MD, both of New York University School of Medicine, “this study confirms a glaring lack of progress, with the persisting high use of CVCs at dialysis initiation complicated by a high risk for [bloodstream infections] BSI.”
In an editorial accompanying the study, they argued that one reason for the continued use of CVC despite evidence indicating poor health outcomes is the “disjointed health care system” in the United States.
“The startling reality that CVC use in the U.S. remains unchanged among incident HD patients, despite a national goal to decrease their utilization, points to the possibility that systemic barriers have created a culture that favors using CVCs,” they wrote, adding that fistula use is two to three times greater in most European countries, as well as in Japan.
“Unfortunately, they contended, “a culture is not something easily changed by individual initiatives, but rather requires a collaborative effort from a variety of stakeholders.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
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Kazakova SV, et al. Kidney Med. 2020;doi:10.1016/j.xkme.2019.12.010.
Packer D and Kaufman JS. Kidney Med. 2020;doi:10.1016/j.xkme.2020.04.004.
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