Trends in Mortality of Patients with Central Venous Catheters versus Arteriovenous Accesses for Hemodialysis.

BACKGROUND

Guidelines favor arteriovenous (AV) access over central venous catheters (CVCs) for hemodialysis due in part to lower infection risk. Nevertheless, most patients initiate hemodialysis with a CVC. We used US Renal Data System data to evaluate whether the comparative mortality risk of these vascular access strategies has changed over time among patients with incident kidney failure.

METHODS

In this observational study, we evaluated community-dwelling, functionally independent adults (aged 18-85 years) initiating hemodialysis with a CVC in 2013-2022, excluding those with a maturing AV access to prevent immortal time bias. We used the clone-censor-weighting approach, a causal inference method for evaluating dynamic treatment patterns, to compare continuous CVC use versus transition to an AV access. Inverse-probability-of-censoring weighted discrete-time pooled logistic regression modeled the 18-month cumulative risk of death by hemodialysis initiation year, with modality changes treated as competing events.

RESULTS

Among 536,836 incident patients, 71,443 and 63,875 deaths occurred in the CVC and AV access groups, respectively. From 2013 to 2022, the adjusted 18-month cumulative risk of death declined from 26.8% to 21.3% in the CVC group, and from 20.9% to 17.1% in the AV access group. Correspondingly, the absolute risk difference comparing CVC versus AV access attenuated by nearly 30% (from 5.9 [95% CI 5.4, 6.3] to 4.2 [95% CI 3.9, 4.5] deaths per 100 patients), whereas the relative risk declined by 3% (from 1.28 [95% CI 1.26, 1.30] to 1.25 [95% CI 1.23, 1.27]). Bloodstream infection-related deaths showed similar declining risk patterns, with a proportionally larger attenuation in absolute risk difference and a greater decline in relative risk between groups.

CONCLUSIONS

Mortality rates declined among patients initiating hemodialysis with a CVC over the past decade, which has led to a reduction in the absolute excess risk associated with continued CVC use.