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Increased Arteriovenous Fistula Cannulation Rate at Index Hemodialysis Has Not Impacted Catheter Usage Over the First Five Years of the Fistula First Breakthrough Initiative
Devin S. Zarkowsky, MD, Joseph Canner, MHS, Isidor Arhuidese, MD MHS, Eric Schneider, PhD, Umair Qazi, MD, MPH, James H. Black, III, MD, Julie A. Freischlag, MD, Mahmoud B. Malas, MD MHS.
The Johns Hopkins Hospital, Baltimore, MD, USA.
OBJECTIVES: To examine trends in hemodialysis access methods between 2006 and 2010 in first-time renal replacement therapy patients.
METHODS: An IRB-approved retrospective analysis of a prospectively-maintained database from the United States Renal Data System comprising information on all ESRD patients in the country was performed. Those patients with dialysis access established before 2006 and patients who received a kidney transplant at any time were censored. Chi-square tests and ANOVA provided descriptive statistics.
RESULTS: Between 2006 and 2010, 510,000 patients commenced hemodialysis, 17.4% (17.1-17.9) through permanent surgical access. Intravascular hemodialysis catheters (IHC) were the most common access method employed, 82.6% (82.1-82.9), while arteriovenous fistulae (AVF) and arteriovenous grafts (AVG) were utilized with less frequency, 13.8% (12.2-15.0) and 3.5% (2.9-4.2) respectively. AVF and AVG exhibit a statistically significant inverse relationship over the study period, with AVF access increasing in frequency concurrent with a decrease in AVG (p<0.001, Table 1); incident dialysis via IHC remained essentially unchanged.
CONCLUSIONS:These results quantify a shift in conduit selection, likely owing to increased AVF awareness related to the Fistula First Breakthrough Initiative (FFBI). FFBI targets AVF cannulation at the index hemodialysis episode in 50% of patients, a goal not yet achieved. This initiative succeeded in shifting permanent access creation toward autogenous fistulae at the expense of prosthetic-based fistulae, a trend signaling evolution in surgical decision-making. However, we have failed to impact catheter use. There is a critical need for cultural change among patients and physicians To reduce dialysis initiation through IHC. FFBI began this process in 2006 and it is incumbent on the vascular surgery community to continue challenging educational, cultural and economic barriers preventing ESRD patients from receiving optimum care.
Incident hemodialysis method | AVF (%) | AVG (%) | IHC (%) | | 2006 (n=99,545) | 13,155 (12.2) | 4,181 (4.2) | 82,209 (82.6) | | 2007 (n=100,256) | 13,670 (13.6) | 3,674 (3.7) | 82,912 (82.7) | | 2008 (n=101,253) | 13,933 (13.8) | 3,344 (3.3) | 83,976 (82.9) | | 2009 (n=104,513) | 15,028 (14.4) | 3,309 (3.2) | 86,176 (82.5) | | 2010 (n=104,433) | 15,666 (15.0) | 3,054 (2.9) | 85,713 (82.1) | | p-value | <0.001 | <0.001 | <0.001 |
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