Timing of nephrologist referral and arteriovenous access use: The CHOICE Study

doi:10.1053/ajkd.2001.26833

American Journal of Kidney Diseases

Volume 38, Issue 3, September 2001, Pages 494-501

https://doi.org/10.1053/ajkd.2001.26833 Get rights and content

Abstract

Recent clinical practice guidelines recommend the creation of an arteriovenous (AV) vascular access (ie, native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. We report on the association of referral to a nephrologist with duration of dialysis-catheter use and type of vascular access used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Center Study. Patients who reported being seen by a nephrologist at least 1 month before starting hemodialysis therapy (75%) were more likely than those referred later to use an AV access at initiation (39% versus 10%; P < 0.001) and 6 months after starting hemodialysis therapy (74% versus 56%; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a median of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis therapy, respectively (P trend <0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients referred later to use an AV fistula, rather than a synthetic graft, as their first AV access (45% versus 31%; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, insurance coverage, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist substantially increases the likelihood of dialysis-catheter use at the initiation of hemodialysis therapy and is associated with prolonged catheter use. Regardless of the time of referral, only a minority of patients used an AV access at the initiation of treatment, and greater than 25% had not used an AV access 6 months after initiation. Thus, further efforts to improve both referral patterns and preparation for dialysis after referral are needed. © 2001 by the National Kidney Foundation, Inc.

Section snippets

Study design and population

Study subjects were a subpopulation of patients drawn from dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Cohort Study.¹¹ CHOICE is a national prospective cohort study of incident dialysis patients initiated in 1995 to investigate treatment choices of modality and dose and outcomes of dialysis care. From October 1995 to June 1998, a total of 1,041 patients were enrolled from 80 dialysis clinics associated with Dialysis Clinic,

Patient characteristics

The date of first referral to a nephrologist was available for 499 patients. Type of vascular access in use at initiation of hemodialysis therapy was available for 356 of these patients (71%). These patients were enrolled at 70 clinics. Patient characteristics are listed in Table 1.

. Selected Characteristics of 356 Incident Hemodialysis Patients Enrolled Into the CHOICE Study

Patient Characteristic	No.	%
Age group (y)^*
<50	115	33.3
50-59	62	18.0
60-69	87	25.2
≥70	81	23.5
Women	152	42.7
Black†	108	32.0
High

Discussion

Our results show that patients referred to a nephrologist at least 1 month before the initiation of chronic hemodialysis therapy are more than three times as likely to use an AV access as opposed to a dialysis catheter for their first dialysis session than patients referred later. Early referral also showed a strong dose response with duration of dialysis-catheter use. Patients referred early were also more likely to use an AV fistula, rather than synthetic graft, as their first AV access than

Acknowledgements

The authors thank the patients, staff, and medical directors of the participating clinics at DCI who contributed to the study.

References (22)

NR Powe et al.
Septicemia in dialysis patients: Incidence, risk factors, and prognosis
Kidney Int
(1999)
SJ Schwab et al.
Hemodialysis-associated subclavian vein stenosis
Kidney Int
(1988)
CO Stehman-Breen et al.
Determinants of type and timing of initial permanent hemodialysis vascular access
Kidney Int
(2000)
R Hakim et al.
Hemodialysis access failure: A call to action
Kidney Int
(1998)
S Greenfield et al.
Principles and practice of case mix adjustment: Applications to end-stage renal disease
Am J Kidney Dis
(1994)
DN Churchill et al.
Canadian Hemodialysis Morbidity Study
Am J Kidney Dis
(1992)
PY Fan et al.
Vascular access: Concepts for the 1990s
J Am Soc Nephrol
(1992)
ZJ Twardowski
Percutaneous blood access for hemodialysis
Semin Dial
(1995)
JL Vanherweghem et al.
Complications related to subclavian catheters for hemodialysis. Report and review
Am J Nephrol
(1986)
B Hoen et al.
EPIBACDIAL: A multicenter prospective study of risk factors for bacteremia in chronic hemodialysis patients
J Am Soc Nephrol
(1998)

D Hernandez et al.

Subclavian vascular access stenosis in dialysis patients: Natural history and risk factors

J Am Soc Nephrol

(1998)

Cited by (239)

Association of race and ethnicity with initial surgical hemodialysis access type in a safety net system
2024, Journal of Vascular Surgery
Prior studies have found lower arteriovenous fistula (AVF) creation rates in Black and Hispanic patients. Whether this is due to health care disparities or other differences is unclear. Our objective was to evaluate the racial/ethnic differences in initial surgical access type within a high-volume, safety net system with predominantly Black and Hispanic populations.
A retrospective review of initial hemodialysis (HD) access in consecutive cases between 2014 and 2019 was conducted from all five safety net hospitals in a health care system that primarily treats underserved patients. Patient data collected included race, ethnicity, sex, comorbidities, and initial arteriovenous (AV) access type (AV fistula [AVF] vs AV graft [AVG]). The rates of cephalic vein-based AVF (CAVF; radiocephalic, brachiocephalic) were compared with basilic and brachial vein AVF (BAVF), because the latter are performed as two stages. Bivariate and multivariate logistic regression models were adjusted for demographic and clinical variables to evaluate the relationship between race/ethnicity, surgical access type, and comorbid conditions.
We included 1334 patients (74% Hispanic, 9% Black, 7% Asian, 2% White, 8% other) who underwent first-time surgical HD access creation. The majority were male (818 [63%]). Medical comorbidities were equal among groups, except for chronic obstructive pulmonary disease and stroke, which were higher in Black patients (P < .005 and P = .005, respectively). Overall, 1303 patients (98%) underwent AVF creation and 31 AVG creation (2%), with no difference between race/ethnicity in AVF vs AVG creation. Of the AVF cohort, 991 (76%) had a CAVF and 312 (24%) had a BAVF. Males were more likely than females to get a CAVF (65% vs 35%; P = .002).
Within our safety net health system, where most patients are under-represented minorities, nearly all patients undergoing HD access had an AVF as their initial surgery with no difference in race/ethnicity. AVF type received differed by race, with Black patients twice as likely to undergo BAVF, which required two stages. Further studies are needed to identify the reasons for these differences.
Late creation of vascular access increased post-hemodialysis mortality, hospitalization, and health-care expenditure: A population-based cohort study in Taiwan
2024, Journal of the Formosan Medical Association
The optimal timing of vascular access (VA) creation for hemodialysis (HD) and whether this timing affects mortality and health-care utilization after HD initiation remain unclear. Thus, we conducted a population-based study to explore their association.
We used Taiwan's National Health Insurance Research Database to analyze health-care outcomes and utilization in a cohort initiating HD during 2003–2013. We stratified patients by the following VA creation time points: >180, 91–180, 31–90, and ≤30 days before and ≤30 days after HD initiation and examined all-cause mortality, ambulatory care utilization/costs, hospital admission/costs, and total expenditure within 2 years after HD. Cox regression, Poisson regression, and general linear regression were used to analyze mortality, health-care utilization, and costs respectively.
We identified 77,205 patients who started HD during 2003–2013. Compared with the patients undergoing VA surgery >180 days before HD initiation, those undergoing VA surgery ≤30 days before HD initiation had the highest mortality—15.92 deaths per 100-person-years, crude hazard ratio (HR) 1.56, and adjusted HR 1.28, the highest hospital admissions rates— 2.72 admission per person-year, crude rate ratio (RR) 1.48 and adjusted RR 1.32, and thus the highest health-care costs— US$31,390 per person-year, 7% increase of costs and 6% increase with adjustment within the 2-year follow-up after HD initiation.
Late VA creation for HD can increase all-cause mortality, hospitalization, and health-care costs within 2 years after HD initiation. Early preparation of VA has the potential to reduce post-HD mortality and healthcare expenses for the ESKD patients.
Interdisciplinary Care and Preparedness for Kidney Failure Management in a High-Risk Population
2022, Kidney Medicine
Interdisciplinary care may improve health outcomes in patients with chronic kidney disease (CKD). Few studies have evaluated this model of health care delivery in racial and ethnic minorities.
Retrospective cohort study.
Incident end-stage kidney disease (ESKD) patients at Montefiore Medical Center from October 1, 2013, to October 31, 2019.
Pre-ESKD interdisciplinary care.
Pre-ESKD transplant listing and optimal kidney replacement therapy (KRT) start (use of arteriovenous access at hemodialysis initiation, outpatient hemodialysis start, preemptive transplant, or peritoneal dialysis as the first modality).
We constructed multivariable logistic regression models adjusted for sociodemographic and clinical factors to determine the odds of transplant listing and optimal KRT start between interdisciplinary versus the usual care group.
Of the 295 incident ESKD patients included in our study, 84 received interdisciplinary care and 211 received usual nephrology care. The mean age was 59.9 years (standard deviation, 13.9 years), 47% were women, and 87% were African American or Hispanic. Baseline characteristics were similar between the groups, except that the interdisciplinary care group had a lower prevalence of hypertension (60% vs 75%). Compared with usual care, a higher proportion of patients in the interdisciplinary care group were listed for kidney transplant (44% vs 16%) and had an optimal KRT start (53% vs 44%). Receipt of interdisciplinary care was associated with a higher odds (OR, 5.73; 95% CI, 2.78-11.80; P < 0.001) of transplant listing compared with usual care after adjusting for important sociodemographic and clinical factors. The odds of an optimal KRT start also favored interdisciplinary care (OR, 1.60; 95% CI, 0.88-2.89; P = 0.12) but did not achieve statistical significance.
The study was non-randomized and had a small sample size.
Interdisciplinary care is associated with better ESKD preparedness compared with usual nephrology care alone in racial and ethnic minorities. Larger studies are needed to determine the effectiveness of interdisciplinary care in patients with advanced CKD.
Central Venous Catheters for Hemodialysis—the Myth and the Evidence
2021, Kidney International Reports
Hemodialysis-central venous catheter (HD-CVC) insertion is a most often performed procedure, with approximately 80% of patients with end-stage kidney disease in the United States initiating kidney replacement therapy through a HD-CVC. Certain adverse events arising from HD-CVC placement, including catheter-related bloodstream infections (CR-BSIs), thrombosis, and central vein stenosis, can complicate the clinical course of patients and lead to considerable financial impact on the health care system. Medical professionals with different training backgrounds are responsible for performing this procedure, and therefore, comprehensive operator guidelines are crucial to improve the success rate of HD-CVC insertion and prevent complications. In this review article, we not only discuss the basic principles behind the use of HD-CVCs but also address frequently asked questions and myths regarding catheter asepsis, length selection, tip positioning, and flow rate assessment.
Comparison of Clinical Performance of VectorFlow and Palindrome Symmetric-Tip Dialysis Catheters: A Multicenter, Randomized Trial
2020, Journal of Vascular and Interventional Radiology
To compare clinical performance of 2 widely used symmetric-tip hemodialysis catheters.
Patients with end-stage renal disease initiating or resuming hemodialysis were randomized to receive an Arrow–Clark VectorFlow (n = 50) or Palindrome catheter (n = 50). Primary outcome was 90-d primary unassisted catheter patency. Secondary outcomes were Kt/V ([dialyzer urea clearance × total treatment time]/total volume of urea distribution), urea reduction ratio (URR), and effective blood flow (Q_B).
Primary unassisted patency rates with the VectorFlow catheter at 30, 60, and 90 d were 95.5% ± 3.3, 87.2% ± 7.3, and 80.6% ± 9.8, respectively, compared with 89.1% ± 6.2, 79.4% ± 10.0, and 71.5% ± 12.6 with the Palindrome catheter (P = .20). Patients with VectorFlow catheters had a mean Kt/V of 1.5 at 30-, 60-, and 90-day time points, significantly higher than the mean Kt/V of 1.3 among those with Palindrome catheters (P = .0003). URRs were not significantly different between catheters. Catheter Q_B rates exceeded National Kidney Foundation–recommended thresholds of 300 mL/min at all time points for both catheters and were similar for both catheters (median, 373 mL/min). Catheter failure, ie, poor flow rate requiring guide-wire exchange or removal, within the 90-day primary outcome occurred in 3 VectorFlow subjects and 5 Palindrome subjects (P = .72). Infection rates were similar, with 0.98 infections per 1,000 catheter days for VectorFlow catheters compared with 2.62 per 1,000 catheter days for Palindrome catheters (P = .44).
The 90-day primary patency rates of Palindrome and VectorFlow catheters were not significantly different, and both achieved sustained high Q_B through 90 day follow-up. However, dialysis adequacy based on Kt/V was consistently better with the VectorFlow catheter versus the Palindrome.
Perspectives in Individualizing Solutions for Dialysis Access
2020, Advances in Chronic Kidney Disease
Citation Excerpt :
Astor and colleagues showed in the CHOICE study that patients who were referred late before HD initiation were more likely to start with a CVC as opposed to an AVF or AVG. Annual mortality rates were 11.7% for AVF, 14.2% for AVG, and 16.1% for CVC.37,38 A USRDS study in 16,728 patients with a failed kidney transplant who initiated HD demonstrated that 27.7% (n = 4636) used an AVF, 6.9% (n = 1146) used an AVG, and 65.4% (n = 10,946) used a CVC.39
The vascular access is the lifeline for the hemodialysis patient. Previous national vascular access guidelines have emphasized placement of arteriovenous fistulas in most hemodialysis patients. However, the new Kidney Disease Outcomes Quality Initiative guidelines for vascular access, soon to be published, will focus on a patient's end-stage kidney disease “life plan” and take a patient “first” approach. One of the major themes of the new Kidney Disease Outcomes Quality Initiative guidelines is selecting the “right access, for the right patient, at the right time, for the right reason”. Given the availability of new advances in biomedical technologies, techniques, and devices in the vascular access field, this shift to a more patient-centered vascular access approach presents unique opportunities to individualize the solutions and care for patients requiring a dialysis vascular access. This review article will address 3 potential areas where there is an unmet need to individualize solutions for dialysis vascular access care: (1) biological approaches to improve vascular access selection and selection of therapies, (2) vascular access care for the post-transplant patient, and (3) vascular access disparities in race, gender, and the elderly patient.

View all citing articles on Scopus

^*: For the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study, a Patient Outcomes Research Team studying dialysis care for end-stage renal disease. CHOICE investigators include Neil R. Powe, MD; John H. Sadler, MD; Michael J. Klag, MD; Gerard F. Anderson, PhD; Eric B. Bass, MD; William Briggs, MD; Ronald Brookmeyer, PhD; Josef Coresh, MD, PhD; Nancy E. Fink, MPH; Klemens Meyer, MD; Andrew Levey, MD; Nathan Levin, MD; Haya R. Rubin, MD, PhD; Paul K. Whelton, MD; and Albert W. Wu, MD.

^**: Supported in part by grants no. R01HS08365 from the Agency for Healthcare Research and Quality; R01HL62985 from the National Heart, Lung, and Blood Institute; T32HL07024-23 from the National Heart, Lung, and Blood Institute (B.C.A.); and K24DK02643 (N.R.P.), T32DK07732, K24DK02856 (M.J.K.), R29DK48362 (J.C.), and R010K59616 from the National Institute of Diabetes and Digestive and Kidney Diseases.

^*: Address reprint requests to Josef Coresh, MD, PhD, 2024 East Monument St, Ste 2-600, Baltimore, MD 21205. E-mail: [email protected]

^**: 0272-6386/01/3803-0006$35.00/0

View full text

Original InvestigationsTiming of nephrologist referral and arteriovenous access use: The CHOICE Study*,**,*,**

Abstract

Section snippets

Study design and population

Patient characteristics

Discussion

Acknowledgements

Kidney Int

Kidney Int

Kidney Int

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Vascular access: Concepts for the 1990s

J Am Soc Nephrol

Percutaneous blood access for hemodialysis

Semin Dial

Complications related to subclavian catheters for hemodialysis. Report and review

Am J Nephrol

EPIBACDIAL: A multicenter prospective study of risk factors for bacteremia in chronic hemodialysis patients

J Am Soc Nephrol

Subclavian vascular access stenosis in dialysis patients: Natural history and risk factors

J Am Soc Nephrol

Original Investigations
Timing of nephrologist referral and arteriovenous access use: The CHOICE Study*,**,*,**