Determinants of type and timing of initial permanent hemodialysis vascular access.
BACKGROUND
We undertook a population-based study of hemodialysis (HD) patients to determine which factors are important in predicting the type of permanent access initially placed and if a functional permanent access is in place at the start of HD.


METHODS
Selected characteristics were abstracted from the United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Study (DMMS) Wave 2. Logistic regression was used to estimate the independent contribution of specific characteristics in predicting whether the initial permanent access placed was an arteriovenous (AV) fistula compared with a polytetrafluoroethylene (PTFE) graft, and in predicting whether permanent access (fistula or graft) was in place at the initiation of dialysis.


RESULTS
Sixty-seven percent of the patients had an AV graft placed as their first permanent access. Characteristics important in predicting if a fistula was initially placed included age (per decade; aOR = 0.84, P < 0.001), female gender (aOR = 0.52, P < 0.001), body mass index (per standard deviation; aOR = 0.70, P = 0.09), avoiding blood draws (aOR = 1.96, P < 0.001), ability to ambulate (aOR = 2.24, P = 0.008), underlying renal disease (glomerular compared with diabetes, aOR = 2.19, P = 0.009), college education (aOR = 1.72, P = 0.002), and sharing in decision making (aOR = 1.50, P = 0.02). Thirty-four percent of patients (34.4%) had functional permanent access at the start of HD. Characteristics important in predicting which patients had functional permanent access included serum albumin (per 1 mg/dL increase, aOR =1.55, P = 0.003), erythropoietin prior to starting HD (aOR = 1.79, P = 0.002), fewer predialysis nephrologist visits (aOR = 0.21, P < 0.001), and when the patient was told they had renal disease (aOR = 0.33, P = 0.002).


CONCLUSIONS
PTFE grafts were the most common initial permanent access. The majority of patients did not have permanent access at the start of dialysis. Factors that are thought to compromise identification of adequate veins were important predictors of PTFE graft placement. Permanent access at the start of HD was largely a function of early patient education and early referral to a nephrologist.
Stehman-Breen
C O
CO
Department of Surgery, Veterans Administration Puget Sound Health Care System, Seattle, WA 98108, USA. cos@u.washington.edu
Sherrard
D J
DJ
Gillen
D
D
Caps
M
M
D000368:Aged; D000714:Anastomosis, Surgical / Q000706:statistics & numerical data*; D001807:Blood Vessel Prosthesis / Q000706:statistics & numerical data*; D015992:Body Mass Index; D002408:Catheters, Indwelling / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000706:statistics & numerical data; D010358:Patient Participation; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012709:Serum Albumin / Q000032:analysis; D012737:Sex Factors; D013997:Time Factors; D014680:Veins
D012709:Serum Albumin