Racial Disparities in Arteriovenous Access after Initiation of Hemodialysis with a Catheter
Courtenay Holscher, MD1, Satinderjit Locham, MD2, Hanaa Dakour-Aridi, MD2, Andrew Barleben, MD2, Mahmoud Malas, MD, MHS, FACS2
1John Hopkins Medical Institutes, Baltimore, MD, USA, 2University of California San Diego, La Jolla, CA
OBJECTIVES: Although National Kidney Foundation - Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines have recommended initiation of hemodialysis (HD) with a fistula for over a decade, the majority of patients with ESRD still initiate HD with a catheter. We sought to understand racial disparities in placement of arteriovenous (AV) access after initiation of HD with a catheter and how AV access after initiation of HD with a catheter impacts mortality.
METHODS: All patients initiating HD with a catheter in the United States Renal Data System (USRDS) from 2006 to 2015 were included. Patients were grouped into either undergoing arteriovenous fistula or graft (AVF/AVG) placement versus no subsequent AV access placement. Standard univariate (Student’s t-test, chi-square, Kaplan-Meier survival estimates with log-rank tests) and multivariable (Cox regression) analyses were utilized as appropriate.
RESULTS: Of 450,781 patients who initiated hemodialysis with a catheter, 51% underwent subsequent AV access placement. The majority of patients were male (55%) and Caucasian (61%) with mean age (S.D.) of 64.8(15.0) years. Patients undergoing AV access placement had significantly more comorbidities including smoking (6.7% vs. 6.2%), CHF (36.2% vs. 35.7%), HTN (87.2% vs. 85.2%), and diabetes (57.7% vs. 54.8%)(All P<0.001). The Kaplan-Meier survival estimates at 5-years were significantly lower in patients receiving no AV access versus AVF/AVG access (34.0% vs. 40.3%, P<0.001) (figure). After adjusting for potential confounders, patients with AVF/AVG placement had 33% lower mortality at 5-years than those who continued with a catheter (aHR [95%CI]: 0.67 [0.67-0.68], p<0.001). In multivariable Cox-regression analysis, compared to Caucasians, African Americans were less likely to acquire AVF/AVG access within 5-years following incident catheter HD (aHR [95%CI]: 0.89 [0.88-0.90], P<0.001).
CONCLUSIONS: After starting HD with catheter access, patients who undergo subsequent AVF/AVG placement have 33% lower mortality than those who have no subsequent AV access. Despite having Medicare coverage once on dialysis, African Americans are less likely to undergo AV access placement. Further work is needed to determine where in the referral process these disparities are most marked. 
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