The objective of this study is to examine the association of race with outcomes of hemodialysis access and selection of arteriovenous fistula versus arteriovenous graft” Copeland et al (2019).
Abstract:
BACKGROUND: Black end-stage renal disease (ESRD) patients represent 30.5% of the prevalent ESRD population in the United States, despite only accounting for 18% of the total population. Black patients are less likely to have pre-ESRD care compared to their white counterparts, and are 3 to 4 times more likely to progress from chronic kidney disease to ESRD than whites, suggesting black patients are particularly vulnerable to disparities in outcomes related to hemodialysis and ESRD. The objective of this study is to examine the association of race with outcomes of hemodialysis access and selection of arteriovenous fistula versus arteriovenous graft.
METHODS: Patients with chronic kidney disease who initiated dialysis through a tunneled hemodialysis catheter (THC) were identified in the Optum Clinformatics database (2011-2017). The odds of arteriovenous fistula (AVF) versus arteriovenous graft (AVG) creation and the odds of repeat vascular access creation were analyzed using logistic regression. Time from initial AVF/AVG to THC removal and time to repeat AVF/AVG were analyzed using Cox proportional hazards.
RESULTS: 7,584 vascular access patients met the inclusion criteria: 5,852 (77%) AVF and 1,732 (23%) AVG. Median follow-up was 583 days overall (range 1-2,543), 589 days among AVF patients (range 1-2,543), and 260 days among AVG patients (range 1-2,529). Between races there was no clinically significant variation in characteristics or comorbidities, with the exception of a much lower rate of obesity among Asians. Black patients had 36% lower odds of index AVF versus index AVG (P<0.001). Patients 70 or older and patients with diabetes had lower odds of index AVF, while men and obese patients had greater odds of receiving AVF. Overall, graft patients were 73% more likely to have a shorter time to THC removal than fistula patients, but Hispanic graft patients were 25% more likely to have a shorter time to THC removal than whites. Patients with diabetes, cardiac arrhythmia patients, and obesity were more likely to have a longer time to THC removal. 1,589 (21%) patients underwent a repeat vascular access creation during the follow-up period: 19% of whites (n=802), 26% of blacks (n=483), 19% of Hispanics (n=250), 19% of Asians (n=54) (p<0.001). Multivariate analysis demonstrated black patients had 58% greater odds of requiring a second access than white patients (p<0.001). Graft patients, patients 70 or older, and men had lower odds of repeat access. Black patients were 45% more likely to have a shorter time until second access creation. Graft patients, patients age 70 or older, and men were more likely to have a longer time until second access. Patients with obesity were more likely to have a shorter time until second access. CONCLUSION: This study's findings suggest that after initial vascular access, compared to whites, blacks have no difference in time to index access success, but their access fails earlier and more frequently, independent of access type, age, and co-morbidities. Given blacks constitute 30.5% of the hemodialysis population in the United States, it is imperative future research investigate the root causes of these disparities.
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Reference:
Copeland, T., Hye, R.J., Lawrence, P. and Woo, K. (2019) Association of Race and Ethnicity with Vascular Access Type Selection and Outcomes. Annals of Vascular Surgery. August 30th. doi: 10.1016/j.avsg.2019.08.068. [Epub ahead of print].