Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population

Abstract

Significance Statement Of incident hemodialysis patients in the United States, 80% start hemodialysis on a central venous catheter (CVC). Despite a national push toward arteriovenous fistula and arteriovenous graft use, little is known about the characteristics and natural history of patients who start hemodialysis on a CVC. In an observational cohort study analyzing data from the US Renal Data System for such patients, the authors found that time on a CVC was longer among women compared with men and among black patients compared with whites and other races/ethnicities. Female and black patients also transitioned to arteriovenous fistula less frequently than their counterparts. Strategies to promote more timely transitions to permanent access should focus on groups that lag in transitioning from a CVC to permanent access. Background Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC). Methods To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013. Results At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft. Conclusions Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.

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