Effects of starting hemodialysis with an arteriovenous fistula or central venous catheter compared with peritoneal dialysis: a retrospective cohort study.
BACKGROUND
Although several studies have demonstrated early survival advantages with peritoneal dialysis (PD) over hemodialysis (HD), the reason for the excess mortality observed among incident HD patients remains to be established, to our knowledge. This study explores the relationship between mortality and dialysis modality, focusing on the role of HD vascular access type at the time of dialysis initiation.


METHODS
A retrospective cohort study was performed among local adult chronic kidney disease patients who consecutively initiated PD and HD with a tunneled cuffed venous catheter (HD-TCC) or a functional arteriovenous fistula (HD-AVF) in our institution in the year 2008. A total of 152 patients were included in the final analysis (HD-AVF, n = 59; HD-TCC, n = 51; PD, n = 42). All cause and dialysis access-related morbidity/mortality were evaluated at one year. Univariate and multivariate analysis were used to compare the survival of PD patients with those who initiated HD with an AVF or with a TCC.


RESULTS
Compared with PD patients, both HD-AVF and HD-TCC patients were more likely to be older (p<0.001) and to have a higher frequency of diabetes mellitus (p = 0.017) and cardiovascular disease (p = 0.020). Overall, HD-TCC patients were more likely to have clinical visits (p = 0.069), emergency room visits (p<0.001) and hospital admissions (p<0.001). At the end of follow-up, HD-TCC patients had a higher rate of dialysis access-related complications (1.53 vs. 0.93 vs. 0.64, per patient-year; p<0.001) and hospitalizations (0.47 vs. 0.07 vs. 0.14, per patient-year; p = 0.034) than HD-AVF and PD patients, respectively. The survival rates at one year were 96.6%, 74.5% and 97.6% for HD-AVF, HD-TCC and PD groups, respectively (p<0.001). In multivariate analysis, HD-TCC use at the time of dialysis initiation was the important factor associated with death (HR 16.128, 95%CI [1.431-181.778], p = 0.024).


CONCLUSIONS
Our results suggest that HD vascular access type at the time of renal replacement therapy initiation is an important modifier of the relationship between dialysis modality and survival among incident dialysis patients.
Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto 4202-451, Portugal. coentrao@med.up.pt
Luis
L
Coentrão
Carla
C
Santos-Araújo
Claudia
C
Dias
Ricardo
R
Neto
Manuel
M
Pestana
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data*; D002405:Catheterization, Central Venous / Q000401:mortality*; D062905:Central Venous Catheters; D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000401:mortality*; D011174:Portugal / Q000453:epidemiology; D006435:Renal Dialysis / Q000401:mortality*; D051436:Renal Insufficiency, Chronic / Q000401:mortality* / Q000534:rehabilitation*; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D015996:Survival Rate; D055815:Young Adult