Central Venous Catheters Linked to Hospitalization Risk in Hemodialysis Patients

Laurie Barclay, MD

September 30, 2010

September 30, 2010 — Central venous catheters are linked to hospitalization risk in long-term hemodialysis patients, according to the results of a prospective, observational study reported online September 30 in the Clinical Journal of the American Society of Nephrology.

"Conversion from central venous catheters to a graft or a fistula is associated with lower mortality risk in long-term hemodialysis (HD) patients; however, a similar association with hospitalization risk remains to be elucidated," write Eduardo Lacson, Jr, from Fresenius Medical Care, North America in Waltham, Massachusetts, and colleagues.

The study cohort consisted of all maintenance in-center hemodialysis patients (N = 79,545) who were treated in Fresenius Medical Care, North America legacy facilities; who had baseline laboratory data from December 2006; and who were alive on January 1, 2007. Using Cox statistical models, the investigators studied the association of access conversion, particularly from a catheter to a fistula or a graft, from January 1 through April 30, 2007, with hospitalization risk through April 30, 2008.

On January 1, 2007, a total of 43% of the cohort had fistulas, 29% had catheters, and 27% had grafts. By April 30, 2007, a total of 70,852 patients were still receiving hemodialysis, of whom 19,792 initially had catheters. Of these, only 10.3% (2045 patients) converted to either a graft (n = 561) or a fistula (n = 1484).

Adjusted hazard ratios (HRs) for hospitalization (with catheters as a reference) were similar in patients who converted to grafts or fistulas (0.69) and in patients receiving fistulas only (0.71). However, patients with fistulas or grafts who converted to catheters had an increased risk for hospitalization (HR, 1.22; P for all < .0001).

"Catheters remain associated with the greatest hospitalization risk," the study authors write. "Conversion from a catheter to either graft or fistula had significantly lower hospitalization risk relative to keeping the catheter. Prospective studies are needed to determine whether programs that reduce catheters will decrease hospitalization risk in HD patients."

Limitations of this study include observational design, inability to determine causation, and residual confounding from unmeasured variables such as comorbidity (other than diabetes); medical therapy; and psychosocial, environmental, and economic factors. In addition, this study was unable to track outpatient vascular access procedures and did not address multiple hospitalizations.

"Nevertheless, a strong association exists between the type of vascular access and hospitalization risk for patients who are on maintenance HD—with fistulas having the lowest risk, catheters with the highest, and grafts in between, although the risks that are associated with grafts are much more favorable than those for catheters," the study authors conclude. "Avoiding catheters altogether, particularly in predialysis patients who have chronic kidney disease and are under the care of nephrologists is ideal; however, few will argue against minimizing time at risk on catheters within the dialysis unit, when conversion of extant catheters to arteriovenous accesses, preferably fistulas, is associated not only with greater survival but also less hospitalization. Prospective studies are needed to test whether programs that reduce catheter use will decrease hospitalization risk for HD patients."

All of the study authors are employees of Fresenius Medical Care, North America.

Clin J Am Soc Nephrol. Published online September 30, 2010.

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