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Clinical Research
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The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter

Alian Al-Balas, Timmy Lee, Carlton J. Young, Jeffrey A. Kepes, Jill Barker-Finkel and Michael Allon
JASN December 2017, 28 (12) 3679-3687; DOI: https://doi.org/10.1681/ASN.2016060707
Alian Al-Balas
Divisions of *Nephrology and
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Timmy Lee
Divisions of *Nephrology and
†Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama
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Carlton J. Young
‡Transplant Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and
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Jeffrey A. Kepes
Divisions of *Nephrology and
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Jill Barker-Finkel
Divisions of *Nephrology and
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Michael Allon
Divisions of *Nephrology and
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    Figure 1.

    Flowsheet of patients included in the analysis, including initial vascular access placed, patient events during follow-up, and vascular access in use at the end of patient follow-up. fxn, function; HD, hemodialysis; PD, peritoneal dialysis.

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    Figure 2.

    Patients initiating hemodialysis with a CVC frequently require multiple AVF and AVG placements during follow-up.

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    Figure 3.

    The annual cost is higher in patients who initially receive an AVF rather than an AVG in multiple patient sub-groups. *P<0.05; **P<0.01 for AVG versus AVF. CHF, congestive heart failure; DM, diabetes mellitus.

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    Table 1.

    Comparison of baseline demographics of patients with an initial AVF surgery, AVG surgery, or no access surgery

    ParameterAVFAVGCVCP Value
    No of patients29511371
    Age in yr, mean±SD52±1454±1456±160.05
    Age ≥65 yr, n (%)53 (18)27 (24)20 (28)0.11
    Men, n (%)178 (60)43 (38)31 (44)<0.001
    Black, n (%)260 (88)98 (87)61 (86)0.85
    Diabetes, n (%)145 (49)67 (59)36 (51)0.18
    Hypertension, n (%)281 (95)108 (96)70 (98)0.44
    Coronary artery disease, n (%)66 (22)26 (23)23 (32)0.20
    Heart failure, n (%)81 (27)32 (28)23 (32)0.26
    Cerebrovascular disease, n (%)40 (14)17 (15)7 (10)0.71
    Peripheral vascular disease, n (%)31 (10)16 (14)8 (11)0.58
    • View popup
    Table 2.

    Comparison of annual frequency of vascular access procedures and CRB between patents with an initial AVF surgery, AVG surgery, or no access surgery

    ParameterAVFAVGCVCP ValueP Value
    AVF versus AVGAVF versus CVC
    No. of patients29511371
    CVC exchange, n per patient-yr (95% CI)0.49 (0.44 to 0.53)0.50 (0.44 to 0.57)3.55 (3.09 to 4.07)0.19<0.001
    Angioplasty, n per patient-yr (95% CI)0.63 (0.58 to 0.68)0.58 (0.52 to 0.66)–0.68–
    Thrombectomy, n per patient-yr (95% CI)0.35 (0.31 to 0.38)0.52 (0.45 to 0.59)–0.004–
    All percutaneous procedures, n per patient-yr (95% CI)1.46 (1.39 to 1.54)1.61 (1.49 to 1.73)3.55 (3.09 to 4.07)0.060.002
    Surgical access revisions, n per patient-yr (95% CI)0.42 (0.38 to 0.47)0.19 (0.15 to 0.24)–<0.001–
    Access creations, n per patient-yr (95% CI)0.59 (0.54 to 0.64)0.43 (0.37 to 0.49)–<0.001–
    All surgical procedures, n per patient-yr (95% CI)1.01 (0.95 to 1.08)0.62 (0.55 to 0.70)–<0.001–
    All access procedures, n per patient-yr (95% CI)2.48 (2.38 to 2.58)2.23 (2.09 to 2.37)–0.69–
    CRBs, n per patient-yr (95% CI)0.60 (0.55 to 0.65)0.60 (0.53 to 0.68)4.63 (4.09 to 5.21)0.23<0.001
    Hospitalizations for CRB, n per patient-yr (95% CI)0.24 (0.22 to 0.28)0.18 (0.14 to 0.22)2.06 (1.71 to 2.46)0.32<0.001
    • The frequency of access events or procedures between subgroups (AVF versus AVG, AVF versus CVC, and failed versus successful AVFs) was assessed using negative binomial models to account for the relatively high number of patients with zero counts. 95% CI, 95% confidence interval.

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    Table 3.

    Median annual vascular access-related costs in patients with an initial AVF, an initial AVG, or no access surgery

    ParameterAVFAVGCVCP Value, AVG versus AVFP Value, CVC versus AVF
    No. of patients29511371
    Percutaneous procedures, median $/yr [IQR]1879 [371–4290]2438 [444–4593]3860 [1586–7759]0.28<0.001
    Surgical access procedures, median $/yr [IQR]4857 [2523–8835]2819 [1411–4274]–<0.001–
    Hospitalization for CRB, median $/yr [IQR]0 [0–6345]0 [0–7171]26,709 [9746–56,794]0.13<0.001
    Total access-related cost, median $/yr [IQR]10,642 [5406–19,878]6810 [3718–13,651]28,709 [11,793–66,917]0.001<0.001
    • View popup
    Table 4.

    Cost of access-related procedures in patients with an initial AVG, a successful AVF, or a failed AVF

    ParameterAVGAVF-SAVF-FP ValueP Value
    AVF-S versus AVGAVF-F versus AVF-S
    No. of patients113190105
    Percutaneous procedures, median $/yr [IQR]2438 [444–4593]1438 [0–3527]2892 [1277–5518]<0.01<0.001
    Surgical access procedures, median $/yr [IQR]2819 [1411–4274]4675 [2277–8234]5501 [2948–10,281]<0.0010.03
    Hospitalization for CRB, median $/yr [IQR]0 [0–7171]0 [0–2020]5693 [1908–16,361]0.06<0.001
    Total access-related cost, median $/yr [IQR]6810 [3718–13,651]8146 [4014–14,397]16,652 [9938–33,053]0.46<0.001
    • AVF-S, successful arteriovenous fistula; AVF-F, failed arteriovenous fistula.

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Journal of the American Society of Nephrology: 28 (12)
Journal of the American Society of Nephrology
Vol. 28, Issue 12
December 2017
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The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter
Alian Al-Balas, Timmy Lee, Carlton J. Young, Jeffrey A. Kepes, Jill Barker-Finkel, Michael Allon
JASN Dec 2017, 28 (12) 3679-3687; DOI: 10.1681/ASN.2016060707

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The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter
Alian Al-Balas, Timmy Lee, Carlton J. Young, Jeffrey A. Kepes, Jill Barker-Finkel, Michael Allon
JASN Dec 2017, 28 (12) 3679-3687; DOI: 10.1681/ASN.2016060707
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