The Survival Benefit of “Fistula First, Catheter Last” in Hemodialysis Is Primarily Due to Patient Factors

Abstract

Patients needing hemodialysis are advised to have arteriovenous fistulas rather than catheters because of significantly lower mortality rates. However, disparities in fistula placement raise the possibility that patient factors have a role in this apparent mortality benefit. We derived a cohort of 115,425 patients on incident hemodialysis ≥67 years old from the US Renal Data System with linked Medicare claims to identify the first predialysis vascular access placed. We compared mortality outcomes in patients initiating hemodialysis with a fistula placed first, a catheter after a fistula placed first failed, or a catheter placed first (n=90,517; reference group). Of 21,436 patients with a fistula placed first, 9794 initiated hemodialysis with that fistula, and 8230 initiated dialysis with a catheter after failed fistula placement. The fistula group had the lowest mortality over 58 months (hazard ratio, 0.50; 95% confidence interval, 0.48 to 0.52; P<0.001), with mortality rates at 6, 12, and 24 months after initiation of 9%, 17%, and 31%, respectively, compared with 32%, 46%, and 62%, respectively, in the catheter group. However, the group initiating hemodialysis with a catheter after failed fistula placement also had significantly lower mortality rates than the catheter group had over 58 months (hazard ratio, 0.66; 95% confidence interval, 0.64 to 0.68; P<0.001), with mortality rates of 15%, 25%, and 42% at 6, 12, and 24 months, respectively. Thus, patient factors affecting fistula placement, even when patients are hemodialyzed with a catheter instead, may explain at least two thirds of the mortality benefit observed in patients with a fistula.

The Interdisciplinary Chronic Kidney Disease Clinic: End of the Beginning, Not Beginning of the End

“…This finding adds to the recent studies by Quinn et al [2] and Brown et al [3] that propose a more nuanced view of the optimal care of patients with chronic kidney disease (CKD) stages 4 and 5. In these studies, patients who underwent an ultimately non-successful AVF placement and initiated dialysis with a hemodialysis catheter had improved mortality compared to those who had initiated dialysis with a catheter and had yet not undergone AVF construction.…”

“…The results of Quinn et al [2] and Brown et al [3] augment and complement the growing body of literature that demonstrates the benefits of pre-ESRD nephrology care, particularly in the form of an interdisciplinary CKD clinic. Pre-ESRD nephrology education using an interdisciplinary approach results in more patients beginning dialysis at home, and also leads to a greater percentage of patients with a permanent access when in-center hemodialysis is chosen [4] .…”

Effect of Age on the Association of Vascular Access Type with Mortality in a Cohort of Incident End-Stage Renal Disease Patients

“…Findings similar to our study were also reported recently by Brown et al, who showed that patients initiating hemodialysis with a TDC after failed AVF placement had significantly lower all-cause mortality rates than the TDC-only group, but higher mortality than patients initiating dialysis using an AVF. [24]…”

Pre-End-Stage Renal Disease Care and Early Survival among Incident Dialysis Patients in the US Military Health System

“…However, only 2.3% of deaths were access related; thus, the excess mortality in patients with catheters did not appear to be causally related to the catheters but may instead reflect underlying poor clinical status. In a USRDS study of 115,425 incident HD patients, Brown et al [41] reported that the group initiating dialysis with a catheter after a failed fistula placement had significantly lower mortality rates than the group who had a catheter placed first and used upon dialysis initiation (AHR 0.66, 95% CI 0.64-0.68). Thus, the actual mortality attributed to the catheter itself may be explained to a large degree by underlying patient factors.…”