The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter

Abstract

Patients in the United States frequently initiate hemodialysis with a central venous catheter (CVC) and subsequently undergo placement of a new arteriovenous fistula (AVF) or arteriovenous graft (AVG). Little is known about the clinical and economic effects of initial vascular access choice. We identified 479 patients starting hemodialysis with a CVC at a large medical center (during 2004-2012) who subsequently had an AVF (=295) or AVG (=105) placed or no arteriovenous access (CVC group, =71). Compared with patients receiving an AVG, those receiving an AVF had more frequent surgical access procedures per year (1.01 [95% confidence interval, 0.95 to 1.08] versus 0.62 [95% confidence interval, 0.55 to 0.70];<0.001) but a similar frequency of percutaneous access procedures per year. Patients receiving an AVF had a higher median annual cost (interquartile range) of surgical access procedures than those receiving an AVG ($4857 [$2523-$8835] versus $2819 [$1411-$4274]; <0.001), whereas the annual cost of percutaneous access procedures was similar in both groups. The AVF group had a higher median overall annual access-related cost than the AVG group ($10,642 [$5406-$19,878] versus $6810 [$3718-$13,651]; =0.001) after controlling for patient age, sex, race, and diabetes. The CVC group had the highest median annual overall access-related cost ($28,709 [$11,793-$66,917];<0.001), largely attributable to the high frequency of hospitalizations due to catheter-related bacteremia. In conclusion, among patients initiating hemodialysis with a CVC, the annual cost of access-related procedures and complications is higher in patients who initially receive an AVF versus an AVG.

Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare Experience

“…In their first year, the average annual cost of an AVF is $10,642 vs. $6810 in an AVG. The CVC group had the highest median annual access-related cost of $28,709 largely attributed to high frequency hospitalisations due to bacteraemia, repeated use of thrombolytics, and frequent catheter replacement [83].…”

Cefazolin–gentamicin versus taurolidine–citrate for the prevention of infection in tunneled central catheters in hemodialysis patients: A quasi-experimental trial

“…Hemodialysis (HD) is the most widely used dialysis therapy in the world, and vascular access represents an important risk factor for bacteremia, hospitalization, and mortality (Sesso et al, 2016;Niyyar, 2012;Lok and Mokrzycki, 2011;Al-Balas et al, 2017;Vascular Access 2006Work Group, 2006. In particular, catheter-related bloodstream infection (CR-BSI) is a severe complication that requires hospitalization, systemic antibiotic therapy, and removal, reinsertion or replacement of the catheter (The NIH, 2016;Lee, 2017;Sequeira et al, 2017).…”

Influence of artery and vein diameters on autogenous arteriovenous access patency

“…United States Renal Data System data demonstrate that 35.9% of autogenous access attempts fail to mature, 5 and 80% of incident dialysis patients initiate dialysis with a tunneled catheter. 6,7 These failures increase the need for adjunct surgical or interventional procedures to facilitate or to re-establish patency, with substantial associated cost 8,9 and morbidity. 8 Preoperative duplex ultrasound vessel mapping is one of several recommended tools to guide access placement to optimize maturation and patency.…”