title: Association of Vascular Access Type with Mortality, Hospitalization, and Transfer to In-Center Hemodialysis in Patients Undergoing Home Hemodialysis.
abstract: OBJECTIVE
  In individuals undergoing in-center hemodialysis (HD), use of central venous catheters (CVCs) is associated with worse clinical outcomes compared with use of arteriovenous access. However, it is unclear whether a similar difference in risk by vascular access type is present in patients undergoing home HD.
  
  
  METHODS
  Our study examined the associations of vascular access type with all-cause mortality, hospitalization, and transfer to in-center HD in patients who initiated home HD from 2007 to 2011 in 464 facilities in 43 states in the United States. Patients were followed through December 31, 2011. Data were analyzed using competing risks hazards regression, with vascular access type at the start of home HD as the primary exposure in a propensity score-matched cohort (1052 patients; 526 with CVC and 526 with arteriovenous access).
  
  
  RESULTS
  Over a median follow-up of 312 days, 110 patients died, 604 had at least one hospitalization, and 202 transferred to in-center hemodialysis. Compared with arteriovenous access use, CVC use was associated with higher risk for mortality (hazard ratio, 1.73; 95% confidence interval, 1.18 to 2.54) and hospitalization (hazard ratio, 1.19; 95% confidence interval, 1.02 to 1.39). CVC use was not associated with increased risk for transfer to in-center HD. The results of analyses in the entire unmatched cohort (2481 patients), with vascular access type modeled as a baseline exposure at start of home HD or a time-varying exposure, were similar. Analyses among a propensity score-matched cohort of patients undergoing in-center HD also showed similar risks for death and hospitalization with use of CVCs.
  
  
  CONCLUSIONS
  In a large cohort of patients on home HD, CVC use was associated with higher risk for mortality and hospitalization. Additional studies are needed to identify interventions which may reduce risk associated with use of CVCs among patients undergoing home HD.
authors.affiliation: Department of Medicine, Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington; mbr@uw.edu.
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Rivara
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California;
authors.forename: Melissa
authors.initials: M
authors.lastname: Soohoo
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California;
authors.forename: Elani
authors.initials: E
authors.lastname: Streja
authors.affiliation: Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee;
authors.forename: Miklos Z
authors.initials: MZ
authors.lastname: Molnar
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California;
authors.forename: Connie M
authors.initials: CM
authors.lastname: Rhee
authors.affiliation: Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah;
authors.forename: Alfred K
authors.initials: AK
authors.lastname: Cheung
authors.affiliation: Department of Medicine, Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington;
authors.forename: Ronit
authors.initials: R
authors.lastname: Katz
authors.affiliation: Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California; University of California, Los Angeles (UCLA), Center for Health Policy Research, Los Angeles, California;
authors.forename: Onyebuchi A
authors.initials: OA
authors.lastname: Arah
authors.affiliation: Division of Nephrology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California; and Office of the Chief Medical Officer, DaVita, Inc., El Segundo, California.
authors.forename: Allen R
authors.initials: AR
authors.lastname: Nissenson
authors.affiliation: Department of Medicine, Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington;
authors.forename: Jonathan
authors.initials: J
authors.lastname: Himmelfarb
authors.affiliation: Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California;
authors.forename: Kamyar
authors.initials: K
authors.lastname: Kalantar-Zadeh
authors.affiliation: Department of Medicine, Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington;
authors.forename: Rajnish
authors.initials: R
authors.lastname: Mehrotra
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000401:mortality*; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D006437:Hemodialysis, Home / Q000009:adverse effects / Q000401:mortality*; D006760:Hospitalization; D006801:Humans; D007674:Kidney Diseases / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: arteriovenous fistula; arteriovenous graft; central venous catheters; end-stage renal disease; follow-up studies; home hemodialysis; hospitalization; humans; mortality risk; vascular access