title: Hemodialysis access usage patterns in the incident dialysis year and associated catheter-related complications.
abstract: BACKGROUND
  Hemodialysis (HD) access is considered a critical and actionable determinant of morbidity, with a growing literature suggesting that initial HD access type is an important marker of long-term outcomes. Accordingly, we examined HD access during the incident dialysis period, focusing on infection risk and successful fistula creation during the first dialysis year.
  
  
  METHODS
  Longitudinal cohort.
  
  
  METHODS
  All US adults admitted to Fresenius Medical Care North America facilities within 15 days of first maintenance dialysis session between January 1 and December 31, 2007.
  
  
  METHODS
  Vascular access type at HD therapy initiation.
  
  
  RESULTS
  Vascular access type at 90 days and at the end of the first year on HD therapy, bloodstream infection within the first year by access type, and catheter complication rate.
  
  
  RESULTS
  Of 25,003 incident dialysis patients studied, 19,622 (78.5%) initiated dialysis with a catheter; 4,151 (16.6%), with a fistula; and 1,230 (4.9%), with a graft. At 90 days, 14,105 (69.7%) had a catheter, 4,432 (21.9%) had a fistula, and 1,705 (8.4%) had a graft. Functioning fistulas and grafts at dialysis therapy initiation had first-year failure rates of 10% and 15%, respectively. Grafts were seldom replaced by fistulas (3%), whereas 7,064 (47.6%) of all patients who initiated with a catheter alone still had only a catheter at 1 year. Overall, 3,327 (13.3%) patients had at least one positive blood culture during follow-up, with the risk being similar between the fistula and graft groups, but approximately 3-fold higher in patients with a catheter (P<0.001 for either comparison). Nearly 1 in 3 catheters (32.5%) will require tissue plasminogen activator use by a median of 41 days, with 59% requiring more than one tissue plasminogen activator administration.
  
  
  CONCLUSIONS
  Potential underestimation of bacteremia because follow-up blood culture results did not include samples sent to local laboratories.
  
  
  CONCLUSIONS
  In a large and representative population of incident US dialysis patients, catheter use remains very high during the first year of HD care and is associated with high mechanical complication and bloodstream infection rates.
authors.affiliation: Division of Hospital Medicine, Department of Medicine, University of California San Diego, San Diego, CA, USA. huxue@mail.ucsd.edu
authors.forename: Hui
authors.initials: H
authors.lastname: Xue
authors.forename: Joachim H
authors.initials: JH
authors.lastname: Ix
authors.forename: Weiling
authors.initials: W
authors.lastname: Wang
authors.forename: Steven M
authors.initials: SM
authors.lastname: Brunelli
authors.forename: Michael
authors.initials: M
authors.lastname: Lazarus
authors.forename: Raymond
authors.initials: R
authors.lastname: Hakim
authors.forename: Eduardo
authors.initials: E
authors.lastname: Lacson
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D055499:Catheter-Related Infections / Q000453:epidemiology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D006435:Renal Dialysis / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States; D062666:Vascular Access Devices / Q000009:adverse effects*; D058017:Vascular Grafting