Transplant waitlisting attenuates the association between hemodialysis access type and mortality
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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.
KeywordsHemodialysis access End-stage renal disease Kidney transplantation Transplant waitlisting
This work was supported by Grants number F32DK109662 and K24DK101828 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), F32AG053025 from the National Institute on Aging (NIA), and an American College of Surgeons Resident Research Scholarship. The analyses described here are the responsibility of the authors alone and do not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products or organizations imply endorsement by the US Government.
Compliance with ethical standards
Conflict of interest
The authors of this manuscript have no conflicts of interest to disclose.
This study was considered exempt non-human subject research by the Johns Hopkins Medicine Institutional Review Board.
- 1.Saran R, Robinson B, Abbott KC, Agodoa LYC, Bhave N, Bragg-Gresham J, Balkrishnan R, Dietrich X, Eckard A, Eggers PW, Gaipov A, Gillen D, Gipson D, Hailpern SM, Hall YN, Han Y, He K, Herman W, Heung M, Hirth RA, Hutton D, Jacobsen SJ, Jin Y, Kalantar-Zadeh K, Kapke A, Kovesdy CP, Lavallee D, Leslie J, McCullough K, Modi Z, Molnar MZ, Montez-Rath M, Moradi H, Morgenstern H, Mukhopadhyay P, Nallamothu B, Nguyen DV, Norris KC, O’Hare AM, Obi Y, Park C, Pearson J, Pisoni R, Potukuchi PK, Rao P, Repeck K, Rhee CM, Schrager J, Schaubel DE, Selewski DT, Shaw SF, Shi JM, Shieu M, Sim JJ, Soohoo M, Steffick D, Streja E, Sumida K, Tamura MK, Tilea A, Tong L, Wang D, Wang M, Woodside KJ, Xin X, Yin M, You AS, Zhou H, Shahinian V (2018) US renal data system 2017 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis 71(3s1):A7. https://doi.org/10.1053/j.ajkd.2018.01.002 CrossRefGoogle Scholar
- 6.Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, Held PJ, Port FK (1999) Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 341(23):1725–1730. https://doi.org/10.1056/nejm199912023412303 CrossRefGoogle Scholar
- 14.Stuart EA, King G, Imai K, Ho D (2011) MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw 42:(8)Google Scholar
- 18.Zarkowsky DS, Hicks CW, Arhuidese I, Canner JK, Obeid T, Qazi U, Schneider E, Abularrage CJ, Black JH, Freischlag JA, Malas MB (2015) Quality improvement targets for regional variation in surgical end-stage renal disease care. JAMA Surg 150(8):764–770. https://doi.org/10.1001/jamasurg.2015.1126 CrossRefGoogle Scholar
- 21.Axelrod DA, Lentine KL, Xiao H, Bubolz T, Goodman D, Freeman R, Tuttle-Newhall JE, Schnitzler MA (2014) Accountability for end-stage organ care: implications of geographic variation in access to kidney transplantation. Surgery 155(5):734–742. https://doi.org/10.1016/j.surg.2013.12.010 CrossRefGoogle Scholar
- 25.Udayaraj U, Ben-Shlomo Y, Roderick P, Casula A, Dudley C, Johnson R, Collett D, Ansell D, Tomson C, Caskey F (2010) Social deprivation, ethnicity, and access to the deceased donor kidney transplant waiting list in England and Wales. Transplantation 90(3):279–285. https://doi.org/10.1097/TP.0b013e3181e346e3 CrossRefGoogle Scholar