Use Of Tunneled Dialysis Catheters Research Articles

Preoperative Vein Mapping is Not Associated With Arteriovenous Access Type Created But is Associated With Improved Patency

Autogenous arteriovenous (AV) fistulas are preferred for hemodialysis access, with AV grafts (AVGs) reserved for when a suitable vein is unavailable. Preoperative vein mapping can be used to identify usable veins for autogenous access. We evaluated whether vein mapping is associated with access type and outcomes. We queried the Vascular Quality Initiative database for patients who had undergone initial AV access creation from 2011 to 2019. We evaluated the associations of preoperative vein ultrasound/venogram mapping with patient characteristics, access type, and 30-day and 1-year patency. Of 20,461 patients receiving an initial AV access, 92% had undergone preoperative vein mapping. The patients who had undergone vein mapping were more likely to be women (43.1% vs 39.8%; P = .01), outpatients (84.1% vs 81.2%; P = .002), obese (43.3% vs 39.2%; P = .002), and diabetic (62.6% vs 59.8%; P = .03). They were also more likely to have concomitant coronary artery disease (21.8% vs 18.9%; P = .008), congestive heart failure (31.3% vs 25.9%; P < .001), and concurrent tunneled dialysis catheters (43.7% vs 35%; P < .001) and to already require dialysis (55.8% vs 52%; P = .004). We found no significant difference in AVG creation between the patients who had and had not undergone vein mapping (14.2% vs 13.6%; P = .5). Furthermore, no significant correlation was found between the proportions of preoperative vein mapping and AVG creation at the center and regional levels (P = .14 and P = .1; and P = .4 and P = .11, respectively). Preoperative vein mapping was associated with higher 30-day patency (94.7% vs 90%; P = .001) and 1-year patency (90% vs 82%; P < .001) for autogenous access. On multivariable analysis, concurrent tunneled dialysis catheter use, congestive heart failure, coronary artery disease, obesity, female sex, and outpatient status were independently associated with increased preoperative vein mapping use (P < .05 for all). Preoperative vein mapping was not independently associated with AVG creation likelihood (odds ratio, 0.98; 95% confidence interval [CI], 0.81-1.17; P = .8) but was independently associated with increased 30-day patency (odds ratio, 2.23; 95% CI, 1.44-3.45; P < .001) and 1-year patency (hazard ratio, 1.56; 95% CI, 1.19-2.04; P = .001). Preoperative vein mapping was more likely to be performed in patients presenting with cardiovascular comorbidities and potential technical concerns. Vein mapping did not appear to minimize AVG creation; however, it was associated with improved autogenous access patency. Although most patients received preoperative vein mapping, increasing its use might further improve access outcomes.

Association of Medicaid Expansion with Tunneled Dialysis Catheter Use at the Time of First Arteriovenous Access Creation

BackgroundIn the United States, many low-income patients initiating hemodialysis are uninsured before qualifying for Medicare. Inadequate access to predialysis care may delay their arteriovenous (AV) access creation and increase tunneled dialysis catheter (TDC) use. The 2014 Affordable Care Act expanded eligibility for Medicaid among low-income adults, but not every state adopted this measure. We evaluated whether Medicaid expansion was associated with decreased TDC use for hemodialysis initiation. MethodsWe queried the United States Vascular Quality Initiative state-level database for non-Medicare patients undergoing initial AV access creation from 2011 to 2018. We evaluated associations of receiving initial AV access in states that expanded Medicaid with concurrent TDC use, survival, and insurance coverage. ResultsData were available for patients in 31 states: 19 states expanded Medicaid from January 2014 to February 2015. Among 8462 patients in the postexpansion period from March 2015 to December 2018, 58% were in Medicaid expansion states. Patients in Medicaid expansion states less often had concurrent TDCs (40% vs. 48%, P < 0.001). In multivariable analysis, Medicaid expansion was independently associated with fewer TDCs (OR 0.7, 95% CI 0.6–0.8, P < 0.001). Three-year survival was similar between patients in Medicaid expansion and nonexpansion states (84.7% vs. 85.2%, P = 0.053). Multivariable cox-regression confirmed the finding (HR 0.95, 95% CI 0.82–1.1, P = 0.482). In difference-in-differences analysis, Medicaid expansion was associated with a 9.2-percentage point increase in Medicaid coverage (95% CI 2.7–15.8, P = 0.009). Hispanic patients exhibited a 30.1-percentage point increase in any insurance coverage (95% CI 0.3–59.9, P = 0.048). ConclusionsPatients in Medicaid expansion states were less likely to have TDCs during initial AV access creation, suggesting earlier predialysis care. Hispanic patients benefited from increased insurance coverage. Expanding insurance options for the underserved may improve quality metrics and cost-savings for hemodialysis patients.

Long-term Tunneled Dialysis Catheter Use Is Not Associated With Mortality but Is Associated With Increased Morbidity

Tunneled dialysis catheters (TDCs) are used as temporary means to provide hemodialysis until permanent arteriovenous (AV) access is established. However, some patients may have TDC long term. Our objective was to evaluate patient characteristics and the reasons for and mortality associated with long-term TDC use. A retrospective single-institution analysis was performed. Long-term TDC use was defined as >180 days without more than a 7-day temporary removal time. Reasons for long-term TDC use and complications were recorded. Summary statistics were performed. Multivariable analysis was completed that compared mortality between patients with long-term TDC use with a comparison cohort who underwent AV access creation with subsequent TDC removal. We identified 50 patients with long-term TDC use from 2013 to 2018. The average age was 63 years, 44% were male, and 76% were African American. Previous TDC use was found in 42%. Median TDC duration was 333 days (range, 185-2029 days). The primary reasons for long-term TDC use were failed AV access (34%), nonmaturing AV access (32%), delayed AV access placement (14%), no AV access options (10%), patient refusal for AV access placement (6%), and medically high risk for AV access placement (4%). In 46% of patients, TDC complications occurred, including central venous stenosis (33.4%), TDC-related infections (29.6%), TDC displacement (27.8%), and thrombosis (7.9%). Overall, 47.6% required a catheter exchange. The majority (76.4%) had their catheter removed during follow-up. The long-term TDC group, in relation to the comparator group (n = 201), had fewer men (44% vs 61.2%; P = .028) and higher proportion of congestive heart failure (66% vs 40.3%; P = .001). Kaplan-Meier analysis showed no significant difference in survival at 24 months for the long-term TDC to the comparator group (93.6% vs 92.7%; P = .28). In multivariable analysis, long-term TDC use was not associated with mortality (hazard ratio, 0.72; 95% confidence interval, 0.29-1.8; P = .48). As expected, patients with long-term TDCs experienced significant TDC-related morbidity; however, long-term TDC use was not associated with increased mortality. Whereas permanent access is preferable, some patients may require long-term TDC use because of difficulty in establishing a permanent access, limited access options, and patient preference.

Reasons for long-term tunneled dialysis catheter use and associated morbidity

ObjectiveTunneled dialysis catheters (TDCs) are generally used as a temporary means to provide hemodialysis until permanent arteriovenous (AV) access is established. However, some patients may have long-term catheter-based hemodialysis because of the lack of alternatives for other dialysis access. Our objective was to evaluate characteristics of patients with, reasons for, and mortality associated with long-term TDC use. MethodsA retrospective single-institution analysis was performed. Long-term TDC use was defined as >180 days without more than a 7-day temporary removal time. Reasons for long-term TDC use and complications were recorded. Summary statistics were performed. Kaplan-Meier analysis compared mortality between patients with long-term TDC use and a comparison cohort who underwent AV access creation with subsequent TDC removal. ResultsWe identified 50 patients with long-term TDC use from 2013 to 2018. The average age was 63 years, 44% were male, and 76% were African American. Previous TDC use was found in 42% of patients with subsequent removal after alternative access was established. Median TDC duration was 333 days (range, 185-2029 days). The primary reasons for long-term TDC use were failed (occluded) AV access (34%), nonmaturing AV (nonoccluded) access (32%), delayed AV access placement (14%), no AV access options (10%), patient refusal for AV access placement (6%), and medically high risk for AV access placement (4%). In 46% of patients, TDC complications including central venous stenosis (33.4%), TDC-related infections (29.6%), TDC displacement (27.8%), and thrombosis (7.9%) occurred. Overall, 47.6% required a catheter exchange during the prolonged TDC period. The majority (76.4%) had the catheter removed because of established alternative access during follow-up. The long-term TDC group, in relation to the comparator group (n = 201), had fewer male patients (44% vs 61.2%; P = .028) and higher proportion of congestive heart failure (66% vs 40.3%; P = .001). Kaplan-Meier analysis showed no significant difference in survival at 24 months for the long-term TDC group compared with the comparator group (93.6% vs 92.7%; P = .28). ConclusionsPatients with long-term TDCs experienced significant TDC-related morbidity. Whereas permanent access is preferable, some patients may require long-term TDC use because of difficulty in establishing a permanent access, limited access options, and patient preference. There was no difference in survival between the groups.

Pre-End-Stage Renal Disease Hemoglobin Variability Predicts Post-End-Stage Renal Disease Mortality in Patients Transitioning to Dialysis

Background: Hemoglobin variability (Hb-var) has been associated with increased mortality both in non-dialysis dependent chronic kidney disease (NDD-CKD) and end-stage renal disease (ESRD) patients. However, the impact of Hb-var in advanced NDD-CKD on outcomes after dialysis initiation remains unknown. Methods: Among 11,872 US veterans with advanced NDD-CKD transitioning to dialysis between October 2007 through September 2011, we assessed Hb-var calculated from the residual SD of at least 3 Hb values during the last 6 months before dialysis initiation (prelude period) using within-subject linear regression models, and stratified into quartiles. Outcomes included post-transition all-cause, cardiovascular, and infection-related mortality, assessed in Cox proportional hazards models and adjusted for demographics, comorbidities, length of hospitalization, medications, estimated glomerular filtration rate (eGFR), type of vascular access, Hb parameters (baseline Hb [i.e., intercept] and change in Hb [i.e., slope]), and number of Hb measurements. Results: Higher prelude Hb-var was associated with use of iron and antiplatelet agents, tunneled dialysis catheter use, higher levels of baseline Hb, change in Hb, eGFR, and serum ferritin. After multivariable adjustment, higher prelude Hb-var was associated with higher post-ESRD all-cause and infection-related mortality, but not cardiovascular mortality (adjusted hazard ratios [95% CI] for the highest [vs. lowest] quartile of Hb-var, 1.10 [1.02–1.19], 1.28 [0.93–1.75], and 0.93 [0.79–1.10], respectively). Conclusions: High pre-ESRD Hb-var is associated with higher mortality, particularly from infectious causes rather than cardiovascular causes. Further research is required to clarify the underlying mechanisms and true causal nature of the observed association.