title: Associations between hemodialysis access type and clinical outcomes: a systematic review.
abstract: Clinical practice guidelines recommend an arteriovenous fistula as the preferred vascular access for hemodialysis, but quantitative associations between vascular access type and various clinical outcomes remain controversial. We performed a systematic review of cohort studies to evaluate the associations between type of vascular access (arteriovenous fistula, arteriovenous graft, and central venous catheter) and risk for death, infection, and major cardiovascular events. We searched MEDLINE, EMBASE, and article reference lists and extracted data describing study design, participants, vascular access type, clinical outcomes, and risk for bias. We identified 3965 citations, of which 67 (62 cohort studies comprising 586,337 participants) met our inclusion criteria. In a random effects meta-analysis, compared with persons with fistulas, those individuals using catheters had higher risks for all-cause mortality (risk ratio=1.53, 95% CI=1.41-1.67), fatal infections (2.12, 1.79-2.52), and cardiovascular events (1.38, 1.24-1.54). Similarly, compared with persons with grafts, those individuals using catheters had higher risks for mortality (1.38, 1.25-1.52), fatal infections (1.49, 1.15-1.93), and cardiovascular events (1.26, 1.11-1.43). Compared with persons with fistulas, those individuals with grafts had increased all-cause mortality (1.18, 1.09-1.27) and fatal infection (1.36, 1.17-1.58), but we did not detect a difference in the risk for cardiovascular events (1.07, 0.95-1.21). The risk for bias, especially selection bias, was high. In conclusion, persons using catheters for hemodialysis seem to have the highest risks for death, infections, and cardiovascular events compared with other vascular access types, and patients with usable fistulas have the lowest risk.
authors: University of Calgary, Faculty of Medicine, Department of Medicine, Foothills Medical Centre, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9. pravani@ucalgary.ca
authors: Pietro
authors: P
authors: Ravani
authors: Suetonia C
authors: SC
authors: Palmer
authors: Matthew J
authors: MJ
authors: Oliver
authors: Robert R
authors: RR
authors: Quinn
authors: Jennifer M
authors: JM
authors: MacRae
authors: Davina J
authors: DJ
authors: Tai
authors: Neesh I
authors: NI
authors: Pannu
authors: Chandra
authors: C
authors: Thomas
authors: Brenda R
authors: BR
authors: Hemmelgarn
authors: Jonathan C
authors: JC
authors: Craig
authors: Braden
authors: B
authors: Manns
authors: Marcello
authors: M
authors: Tonelli
authors: Giovanni F M
authors: GF
authors: Strippoli
authors: Matthew T
authors: MT
authors: James
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D002405:Catheterization, Central Venous / Q000009:adverse effects; D015331:Cohort Studies; D003627:Data Interpretation, Statistical; D006801:Humans; D007239:Infections / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D017594:Publication Bias; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D012307:Risk Factors; D016896:Treatment Outcome; D062666:Vascular Access Devices / Q000009:adverse effects