Racial differences in utilization and outcomes of hemodialysis access in the Unites States.

OBJECTIVE: To evaluate patterns of use and outcomes of arteriovenous fistulas and prosthetic grafts within racial categories in a large population based cohort of hemodialysis (HD) patients in the United States. METHODS: A retrospective analysis of white, black, and Hispanic patients in the prospectively maintained United States Renal Database System who had an autogenous fistula or prosthetic graft placed for HD access between January 2007 and December 2014 was performed. Analysis of variance, χ2, t-tests, Kaplan-Meier, log-rank tests, multivariable logistic, and Cox regression analyses were used to evaluate maturation, patency, infection, and mortality. RESULTS: This study of 359,942 patients, composed of 285,781 autogenous fistulas (79.4%) and 74,161 prosthetic grafts (20.6%) placed in 213,877 white (59.4%), 115,727 black (32.2%), and 30,338 Hispanic (8.4%) patients. There was a 11% increase in the risk-adjusted odds of HD catheter use as bridge to autogenous fistula placement in blacks (adjusted odds ratio, 1.11; 95% confidence interval [CI], 1.08-1.14; P < .001) and a 9% increase in Hispanics (adjusted odds ratio, 1.09; 95% CI, 1.05-1.14; P < .001) compared with whites. Fistula maturation for HD access for whites vs blacks vs Hispanics was 77.0% vs 76.3% vs 77.8% (P = .35). After adjusting for covariates, fistula maturation was higher for blacks (adjusted hazard ratio, 1.09; 95% CI, 1.06-1.13; P < .001) and Hispanics (adjusted hazard ratio, 1.13; 95% CI, 1.06-1.20; P < .001) compared with whites. There was no significant difference in prosthetic graft maturation for blacks and Hispanics compared with whites. Primary, primary-assisted, and secondary patency were highest for Hispanic and least for black autogenous fistula recipients. Primary, primary-assisted, and secondary patency was also highest for Hispanic patients who received prosthetic grafts. Prosthetic grafts were associated with a decrease in patency and patient survival compared with fistulas in all racial categories. Mortality was lower for blacks and Hispanics relative to white patients. Initiation of HD with a catheter and conversion to autogenous fistula was associated with decrease in patency and patient survival compared with initiation with a fistula in all racial groups. CONCLUSIONS: Autogenous fistulas are associated with better patency and patient survival compared with prosthetic grafts for all races studied. The use of HD catheter before fistula placement is more prevalent in Hispanic and black patients and is associated with worse patency and patient survival irrespective of race. Fistula and graft patency is highest for Hispanic patients. Patient survival is higher for Hispanic and black patients relative to whites. These associations suggest potential benefit with initiation of HD via autogenous fistula and minimizing temporizing catheter use, irrespective of race.

Hemodialysis and peritoneal dialysis access related outcomes in the pediatric and adolescent population.

BACKGROUND: There is paucity of comparative data on the objective performance of arteriovenous fistulas (AVF), grafts (AVG), hemodialysis (HD) catheter and peritoneal dialysis (PD) catheter in the pediatric population. METHODS: A retrospective analysis of all patients <21 years in the United States Renal Database System who had an AVF, AVG, HD catheter or PD catheter placed for dialysis access between 1/2007 and 12/2014 was performed. Multivariable cox regression was used to evaluate mortality, patency (primary, primary-assisted and secondary), maturation and catheter survival. RESULTS: The 11,575 patients studied comprised of 9445 (82%) HD, 1435 (12%) PD, 528 (4.6%) HD to PD and 167 (1.4%) PD to HD patients. The HD subcohort comprised of 1296 (13.7%) AVF initiates, 199 (2.1%) AVG initiates, 1347 (14.3%) AVF converts after initial HD catheter use, 292 (3.1%) AVG converts and 6311 (67%) patients who persistently utilized HD catheters. There was no difference between PD and HD in patients 0-5 (aHR: 1.36; 95% CI: 0.89-2.07; P = 0.15) and 6-12 years (aHR: 1.05; 95% CI: 0.72-1.52; P = 0.8). However, PD was associated with 73% and 76% increase in mortality relative to HD among patients in the 13-17 (aHR: 1.73; 95% CI: 1.35-2.21; P < 0.001) and 18-20 (aHR: 1.76; 95% CI: 1.38-2.24; P < 0.001) age categories. AVG was associated with 78% increase in mortality compared to AVF (aHR: 1.78; 95% CI: 1.41-2.25; P < 0.001). Persistent use of HD catheters was associated with 29% increase in mortality (aHR: 1.29; 95% CI: 1.07-1.57; P = 0.009) compared to initiation and persistent use of AVF. Conversion from HD catheter to AVF was associated with 66% decrease in mortality compared to persistent HD catheter use (aHR: 0.34; 95% CI: 0.28-0.40; P < 0.001). Primary, primary assisted and secondary patency were higher for AVF compared to AVG. CONCLUSION: There was no difference in risk adjusted mortality between HD and PD in children less than 13 years. PD is associated with higher mortality compared to HD in adolescents. Initiation of HD with AVF is associated with better patency and patient survival relative to AVG and persistent use of HD catheters in pediatric patients irrespective of transplant potential. Conversion from HD catheter to AVF or AVG in patients who inevitably initiate HD with a catheter is associated with better survival compared to persistent HD catheter use. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Survival after major lower extremity amputation in patients with end-stage renal disease.

OBJECTIVE: This study evaluates survival of patients with end-stage renal disease (ESRD) after major lower extremity amputation (MLEA), given the burden of peripheral arterial disease in patients with ESRD, the hindrance posed by cardiovascular disease on their survival, and the national investment in ESRD-related care. METHODS: A retrospective review of all hemodialysis patients (HD) and renal transplant (RT) recipients who underwent MLEA between January 2007 and December 2011 in the United States Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were used to evaluate patient survival among HD patients and RT recipients overall; and within strata of amputation level, gender, and race. RESULTS: There were 32,540 MLEAs (HD, 92%; RT, 8%). Among HD patients, the median survival was 6 months for above knee amputation (AKA) and 16 months for below knee amputation (BKA). The risk-adjusted mortality was higher for AKA compared with BKA (adjusted hazard ratio [aHR], 1.48; 95% confidence interval [CI], 1.44-1.52; P < .001), females compared with males (aHR, 1.04; 95% CI, 1.01-1.08; P = .004), but lower for blacks (aHR, 0.78 95% CI, 0.76-0.81; P < .001) and Hispanics (aHR, 0.74; 95% CI, 0.70-0.79; P < .001) compared with white HD patients. Among RT recipients, the median survival was 16 months for AKA and 47 months for BKA. Mortality was significantly higher for above knee amputees compared with below knee amputees (aHR, 1.83; 95% CI, 1.60-2.10; P < .001). However, there was no difference in mortality between the gender and racial categories of RT recipients. There was a twofold increase in the 30-day mortality (adjusted odd ratio, 1.94; 95% CI, 1.66-2.25; P < .001) and long-term mortality (aHR, 2.18; 95% CI, 2.05-2.32; P < .001) for HD patients relative to RT recipients. CONCLUSIONS: Survival after MLEA is limited in patients with ESRD. It is relatively better for RT recipients compared with HD patients. Mortality was higher for females compared with males, but lower for blacks and Hispanics compared with white HD patients. There were no gender- or race-specific difference in mortality among RT recipients. These estimates of life expectancy should guide the informed decision- making process for patients and their healthcare providers when the need for intervention arises after MLEA in these unique categories of patients.