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Choice of Hemodialysis Extremity Access Can Reduce Catheter Days
Jonathan Levison, MD, Bree Porcelli, BS, Alexis Deitz, Marissa Karchin, Rami Bustami, PhD, MBA, Clifford Sales, MD, MBA.
The Cardiovascular Care Group, Westfield, NJ, USA.
OBJECTIVES: The National Kidney Foundation-Kidney Dialysis Outcomes Quality Initiative (KDOQI) and Fistula First guidelines recommend early evaluation to plan extremity access for the patient with Chronic Kidney Disease. However, 80% of patients initiate hemodialysis through a central venous catheter. We examined our results to determine whether specific extremity access procedures: autogenous fistula (AVF), single stage transposition arteriovenous fistula (SST,) or arteriovenous grafts (AVG) had varying days of catheter use prior to extremity access cannulation.
METHODS: A retrospective review was performed for all patients undergoing creation of an extremity access from 2010 and 2011. Three groups of patients were identified: SST, AVF and AVG. Other data gathered included patient demographics, co-morbidities, diameter of venous anatomy based on preoperative venous duplex mapping, as well as follow-up interventions required to maintain access patency. Total Catheter Days (TCD) were calculated based on identifying the time from access implantation to catheter removal. TCD was compared in the three groups using the Kruskal-Wallis test and chi-square test, respectively. A multivariate linear regression model was used to predict the natural logarithm of TCD by group.
RESULTS: 220 patients with extremity access were included, 50 SST (23%), 64 AVF (29%) and 106 graft (48%). Median follow-up was 10 months. TCD was available for 127 patients (58%) with an overall median of 110 days: 106.5 days for SST, 178.5 for AVF and 69 days for AVG; p<0.001 by the Kruskal-Wallis test. Results from linear regression showed that TCD was significantly longer for AVF when compared to SST. AVG was associated with a significantly shorter TCD when compared to the autogenous fistula groups. (PE = 0.50, 0.75; p<0.001, 0.002, respectively). Results from multivariate logistic regression showed increased likelihood of receiving an AVG in patients with older age, IDDM, obesity, previous HD access, and smaller diameter of venous anatomy (p<0.05).
CONCLUSION: The creation of a SST is preferred over AVF when creating extremity access in patients with an indwelling tunneled catheter. AVG can be considered in patients while attempting to minimize the requirement of an indwelling tunneled catheter.
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