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.