title: Vascular access type, inflammatory markers, and mortality in incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study.
abstract: BACKGROUND
  Few reports have shown an association between access type and inflammatory marker levels in a longitudinal cohort. We investigated the role of access type on serial levels of inflammatory markers and the role of inflammatory markers in mediating the association of access type and risk of mortality in a prospective study of incident dialysis patients.
  
  
  METHODS
  Cohort study, post hoc analysis of the CHOICE (Choices for Healthy Outcomes in Caring for ESRD) Study.
  
  
  METHODS
  In 583 participants, inflammation was assessed by measuring serum C-reactive protein (CRP) and interleukin 6 (IL-6) after access placement and at multiple times during 3 years' follow-up. Type of access was categorized as central venous catheter (CVC), arteriovenous graft (AVG), and arteriovenous fistula (AVF), and changes over time were recorded.
  
  
  METHODS
  Access type, age, sex, race, body mass index, diabetes, cardiovascular disease, and serum albumin level.
  
  
  RESULTS
  CRP level, IL-6 level, and mortality.
  
  
  METHODS
  We used mixed-effects pattern mixture models to study the association between access type and repeated measurements of inflammation and survival analysis to investigate the association of access type and mortality, adjusting for predictors.
  
  
  RESULTS
  In a mixed-effects pattern mixture model, compared with AVFs, the presence of CVCs and AVGs was associated with 62% (P=0.02) and 30% (P=0.05) increases in average CRP levels, respectively. A Cox proportional hazards model yielded nonsignificant associations of CVC and AVG use (vs AVFs) with risk of mortality when adjusted for inflammatory marker levels. Higher CRP levels were associated with increased risk of CVC failure than lower CRP levels.
  
  
  CONCLUSIONS
  CRP and IL-6 measurements not performed for all hemodialysis patients.
  
  
  CONCLUSIONS
  CVCs, compared with AVFs, are associated with a greater state of inflammation in incident hemodialysis patients, and the association of catheter use and mortality may be mediated by access-induced inflammation. Our findings support recommendations for the early removal or avoidance of CVC placements.
authors.affiliation: Department of Medicine, University of California and San Francisco General Hospital, San Francisco, CA. Electronic address: banerjeet@medsfgh.ucsf.edu.
authors.forename: Tanushree
authors.initials: T
authors.lastname: Banerjee
authors.affiliation: Department of Medicine, University Health Network, University of Toronto, Toronto, Canada.
authors.forename: S Joseph
authors.initials: SJ
authors.lastname: Kim
authors.affiliation: Department of Medicine and Public Health, University of Wisconsin, Madison, WI.
authors.forename: Brad
authors.initials: B
authors.lastname: Astor
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Tariq
authors.initials: T
authors.lastname: Shafi
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Josef
authors.initials: J
authors.lastname: Coresh
authors.affiliation: Department of Medicine, University of California and San Francisco General Hospital, San Francisco, CA.
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000401:mortality* / Q000639:trends; D015415:Biomarkers / Q000097:blood; D002405:Catheterization, Central Venous / Q000401:mortality* / Q000639:trends; D002755:Choice Behavior; D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D018836:Inflammation Mediators / Q000097:blood*; D007676:Kidney Failure, Chronic / Q000097:blood / Q000401:mortality* / Q000628:therapy; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D005791:Patient Care / Q000401:mortality / Q000639:trends; D011446:Prospective Studies; D006435:Renal Dialysis / Q000401:mortality* / Q000639:trends; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D018836:Inflammation Mediators
keywords: C-reactive protein (CRP); Cox proportional hazard model; access failure; access patency; biomarker; central venous catheter (CVC); end-stage renal disease (ESRD); hemodialysis; inflammation; interleukin 6 (IL-6); mixed-effects model; vascular access type