Johns Hopkins University School of Medicine, Baltimore, MD, USA.
University of California San Diego, San Diego, CA, USA.
J Nephrol. 2019 Jun;32(3):477-485. doi: 10.1007/s40620-018-00572-0. Epub 2019 Jan 2.
Prior studies have shown that beginning hemodialysis (HD) with a hemodialysis catheter (HC) is associated with worse mortality than with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). We hypothesized that transplant waitlisting would modify the effect of HD access on mortality, given waitlist candidates' more robust health status. Using the US Renal Data System, we studied patients with incident ESRD who initiated HD between 2010 and 2015 with an AVF, AVG, or HC. We used Cox regression including an interaction term for HD access and waitlist status. There were 587,607 patients that initiated HD, of whom 82,379 (14.0%) were waitlisted for transplantation. Only 26,264 (4.5%) were transplanted. Among patients not listed, those with an AVF had a 34% lower mortality compared to HC [adjusted hazard ratio (aHR) 0.66, 95% confidence interval (CI) 0.65-0.67] while those with an AVG had a 21% lower mortality compared to HC (aHR 0.79, 95% CI 0.77-0.81). Transplant waitlisting attenuated the association between hemodialysis access type and mortality (interaction p < 0.001 for both AVF and AVG vs. HC). Among patients on the waitlist, those with an AVF had a 12% lower mortality compared to HC (aHR 0.88, 95% CI 0.84-0.93), while those with an AVG had no difference in mortality (aHR 0.95, 95% CI 0.84-1.08). While all patients benefit from AVF or AVG over HC, the benefit was attenuated in waitlisted patients. Efforts to improve health status and access to healthcare for non-waitlisted ESRD patients might decrease HD-associated mortality and improve rates of AVF and AVG placement.
先前的研究表明，与动静脉瘘（AVF）或动静脉移植物（AVG）相比，开始血液透析（HD）时使用血液透析导管（HC）与死亡率更高相关。我们假设，鉴于候补名单候选人的健康状况更为稳健，移植候补资格会改变 HD 通路对死亡率的影响。我们使用美国肾脏数据系统，研究了 2010 年至 2015 年间开始接受 HD 治疗的、具有初发性终末期肾病的患者，这些患者的 HD 通路分别使用 AVF、AVG 或 HC。我们使用 Cox 回归，包括 HD 通路和候补名单状态的交互项。共有 587607 名患者开始接受 HD 治疗，其中 82379 名（14.0%）正在等待移植。只有 26264 名（4.5%）接受了移植。在未列入名单的患者中，与 HC 相比，使用 AVF 的患者死亡率降低了 34%（调整后的危险比[aHR]0.66，95%置信区间[CI]0.65-0.67），而使用 AVG 的患者死亡率降低了 21%（aHR 0.79，95%CI 0.77-0.81）。移植候补资格削弱了 HD 通路类型和死亡率之间的关联（对于 AVF 和 AVG 与 HC 相比，交互作用 p < 0.001）。在候补名单上的患者中，与 HC 相比，使用 AVF 的患者死亡率降低了 12%（aHR 0.88，95%CI 0.84-0.93），而使用 AVG 的患者死亡率没有差异（aHR 0.95，95%CI 0.84-1.08）。尽管所有患者从 AVF 或 AVG 中获益多于 HC，但在候补名单上的患者中获益被削弱。努力改善非候补名单上的 ESRD 患者的健康状况和获得医疗保健的机会可能会降低与 HD 相关的死亡率，并提高 AVF 和 AVG 的植入率。
