title: Differences in Initial Hemodialysis Vascular Access Use Among Glomerulonephritis Subtypes in the United States.
abstract: BACKGROUND
  The type of vascular access used for hemodialysis affects patient morbidity and mortality. Whether vascular access types differ by glomerulonephritis (GN) subtype in the US hemodialysis population has not been investigated.
  
  
  METHODS
  Cross-sectional observational study.
  
  
  METHODS
  We identified all adult (aged ≥ 18 years) patients within the US Renal Data System who initiated hemodialysis therapy from July 2005 through December 2011 with a diagnosis of end-stage renal disease attributed to any of 4 primary (focal segmental glomerulosclerosis, immunoglobulin A nephropathy [reference group], membranous nephropathy, and membranoproliferative GN) or 2 secondary (lupus nephritis and vasculitis) GN subtypes.
  
  
  METHODS
  GN subtype.
  
  
  RESULTS
  ORs with 95% CIs for arteriovenous fistula versus central venous catheter (CVC) use and for arteriovenous graft versus CVC use were computed using multinomial logistic regression, with adjustment for demographic, socioeconomic, comorbidity, and duration of nephrology care covariates.
  
  
  RESULTS
  Among 29,015 patients, CVC use at initiation of hemodialysis therapy was substantially higher in patients with lupus nephritis (89.2%) or vasculitis (91.2%) compared with patients with primary GN subtypes (72.7%-79.8%). After adjustment and compared with patients with immunoglobulin A nephropathy, patients with lupus nephritis or vasculitis were as likely to have used an arteriovenous graft (ORs of 0.94 [95% CI, 0.70-1.27] and 0.80 [95% CI, 0.56-1.13], respectively) but significantly less likely to have used an arteriovenous fistula (ORs of 0.66 [95% CI, 0.57-0.76] and 0.54 [95% CI, 0.45-0.63], respectively), whereas patients with any comparator primary GN subtype were at least as likely to have used either of these 2 access types.
  
  
  CONCLUSIONS
  Potential misclassification of exposure; residual confounding by unmeasured covariates; inability to determine causes of observed associations; lacking longitudinal data for vascular access use.
  
  
  CONCLUSIONS
  Significant differences in vascular access distributions at initiation of hemodialysis therapy are apparent among GN subtypes. The unacceptably high use of CVCs in patients with lupus nephritis and vasculitis is particularly concerning. Further studies are needed to identify any potentially modifiable factors underlying these findings.
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA. Electronic address: moshaugh@stanford.edu.
authors.forename: Michelle M
authors.initials: MM
authors.lastname: O'Shaughnessy
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Montez-Rath
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
authors.forename: Yuanchao
authors.initials: Y
authors.lastname: Zheng
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Lafayette
authors.affiliation: Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX.
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
mesh_terms: D000328:Adult; D001166:Arteriovenous Shunt, Surgical; D062905:Central Venous Catheters; D003430:Cross-Sectional Studies; D005260:Female; D005921:Glomerulonephritis / Q000145:classification* / Q000150:complications; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods*
keywords: GN subtype; Hemodialysis (HD); IgA nephropathy (IgAN); arteriovenous fistula (AVF); arteriovenous graft (AVG); central venous catheter (CVC); end-stage renal disease (ESRD); focal segmental glomerulosclerosis (FSGS); glomerulonephritis (GN); lupus nephritis; membranoproliferative GN; membranous nephropathy; vascular access; vasculitis