Trends in Vascular Access Placement among Patients Initiating Hemodialysis with a Catheter

Background: Vascular access practice guidelines recommend placement of a permanent vascular access _ arteriovenous fistula (AVF) or graft (AVG) _ to avoid complications associated with central venous catheters (CVC). Despite these guidelines, there has been a recent decrease in pre-dialysis AVF placement and an increase in patients starting hemodialysis with a CVC only. We evaluated whether there has been an increase in the placement of an AVF or AVG in the first six months after dialysis initation to offset the increase in patients starting dialysis with a CVC. Methods: This was a retrospective cohort study using the United States Renal Data System. We identified 522,598 patients initiating hemodialysis with a CVC between 2016 and 2022. The exposure was the calendar year of hemodialysis initiation, and the main outcome was the proportion of patients with placement of an AVF or AVG within 6 months of hemodialysis initiation. Results: The proportion of patients initiating hemodialysis with a CVC only increased from 62% in 2016 to 74% in 2022 (P<0.001), while the proportion receiving an AVF or AVG within six months of dialysis initiation declined from 34% to 26% (P<0.001). In adjusted Fine–Gray competing risk analysis, compared with 2016 as the reference year, hazard ratios for AVF/AVG placement declined markedly beginning in 2019 (sHR 0.89, 95% CI 0.87–0.90 in 2019; 0.77, 0.76–0.78 in 2020; 0.75, 0.74–0.76 in 2021; and 0.69, 0.68–0.70 in 2022). The standardized 6-month cumulative incidence of AVF/AVG placement decreased from 15% in 2016 to 11% in 2022 (P<0.001). Conclusions: Contrary to national vascular access guidelines, there has been a nearly one-third secular decrease in placement of an AVF or AVG among patients initiating hemodialysis with a CVC, compounding the lower rates of access placement prior to dialysis initiation.