haemodialysis vascular access: recent trends from anzdata dr kevan polkinghorne monash medical...
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Haemodialysis Vascular Access: Recent Trends From ANZDATA
Dr Kevan Polkinghorne
Monash Medical Centre
ANZSN September 2007
Vascular Access: ANZDATA 2000 - 2005
• Vascular access type is an important indicator of quality of care in haemodialysis
• Collection of vascular access data by ANZDATA commenced in 1999:– Initially access in use at the end of survey period collected– 31st Oct 2003 – Access at first haemodialysis added
• Now 6+ years of data available for analysis enabling assessment of trends in vascular access use in the “guidelines era”
International trends
• Significant changes in vascular access practice patterns seen in US and Europe
– USRDS
– DOPPS
Graft As First Access Incident Hemodialysis USRDS
USRDS Annual Report 2006
Fistula As First Access Incident Hemodialysis USRDS
USRDS Annual Report 2006
Catheter As First Access Incident Hemodialysis USRDS
USRDS Annual Report 2006
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
Aims & Methods
Key Questions:
Are the recent trends in international catheter rates seen in ANZDATA?
What are the characteristics of incident patients who use catheters?
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
Trends in Incident Vascular Access: ANZDATA 2000 -2004
(1) Incident Cohort: Patients who commenced dialysis
within 60 days of the survey period 2000, 2002, & 2004
(2) 6-8 Month Cohort: Patients on dialysis 6-8 months
after commencement 2000, 2001, 2002, & 2003
(3) Prevalent Cohort: All patients on haemodialysis 2000, 2002, 2004, & 2005
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
Variable 2000 2002 2004 P value
Number of patients 448 477 487
Age years 62.7 (47-72) 62.2 (49-73) 62.5 (51-74) 0.33
% Men 62.5 61 62 0.89
Race %
White 81 80.5 79 0.95
Indigenous 10.5 10.5 11.7
Other 8.5 9 9.2
Body Mass Index %
Underweight 5.8 3.6 4.5 0.02
Normal 43.8 38.8 34.9
Overweight 32.1 35.8 34.5
Obese 18.2 22.3 26.1
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
Variable 2000 2002 2004 P value
Late Referral 25 28.1 33.9 0.01
Ever Smoked 52.5 51.2 52.4 0.93
Cause of ESRD
Glomerulonephritis 32.6 27.5 23.2 <0.001
Diabetes mellitus 16.5 26.6 25.2
Hypertension 12.5 14.7 12.1
Other 38.4 31.2 32.8
Co morbidities
Diabetes 25.5 37.7 42.5 <0.001
Coronary artery disease
36.8 39.4 42.7 0.18
Peripheral vascular disease
23.2 25.6 26.5 0.49
Cerebrovascular disease
13.8 13.8 16 0.54
Hypertension 87.5 89.7 88.9 0.6
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
Vascular Access: Incident Cohort 2000 -2004
56
6
39
50
6
43
43
3
53
020
4060
8010
0
Per
cent
age
2000 2002 2004
CVC
AVGAVF
Unadjusted & Adjusted Incident Rates: Incident Cohort 2000 - 2004
N Unadjusted Adjusted Unadjusted Adjusted2000 342 61.4 59.5 38.6 40.52002 401 56.9 57.7 43.1 42.32004 446 46.9* 47.8* 53.1* 52.2*
Incident CohortsAVF/AVG CVC
*p< 0.05 compared to 2000
Adjusted for age, sex, race, body mass index, late referral, smoking status, etiology of end stage renal disease, history of diabetes, coronary artery disease, peripheral vascular disease, cerebrovascular disease and hypertension
Vascular Access Use 6-8 Months After Starting Dialysis 2000 -2003
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
78
12
10
69
15
16
73
9
19
67
11
220
2040
6080
100
Per
cent
age
2000 2001 2002 2003
CVC
AVGAVF
Unadjusted & Adjusted Incident Rates: 6-8 Months After Starting Dialysis 2000 - 2004
N Unadjusted Adjusted Unadjusted Adjusted2000 314 89.8 90.8 10.2 9.22001 367 83.9 86.1 16.1 13.9*2002 372 81.2 83.6 18.8* 16.2*2003 424 77.6 77.6 22.4* 20.0*
AVF/AVG CVC
*p< 0.05 compared to 2000
Adjusted for age, sex, race, body mass index, late referral, smoking status, etiology of end stage renal disease, history of diabetes, coronary artery disease, peripheral vascular disease, cerebrovascular disease and hypertension
Actual Vascular Access at First Haemodialysis 2003 -2005
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
38
3
59
35
3
62
35
2
63
020
4060
8010
0
Per
cent
age
2003 2004 2005
CVC
AVGAVF
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
Age (per 10 years) *
Race
Cause of ESRD
Referral *
Smoker
Diabetes
Cardiovascular dis *
Peripheral vascular dis
Cerebrovascular dis
Hypertension
18-30 years>30 years
CaucasoidATSI
Other
GNDMHT
other
EarlylLate
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
.25 .5 .67 1 1.5 2 4Odds ratio
Prevalent Vascular Access 2000-2005
Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases
75
18
6
74
17
9
73
14
13
74
12
13
020
4060
8010
0
Per
cent
age
2000 2002 2004 2005
CVC
AVGAVF
2006 Data
33
3
64
0
20
40
60P
erce
ntag
e
* Excludes 22 Units with <6 New Patients in 2006
Haemdialysis Access at First Dialysis (2006)
AVF AVG
Catheter
50
8
42
52
0
48
56
0
44
56
2
41
58
13
29
60
0
40
65
0
35
83
0
17
0
20
40
60
80
Per
cent
age
Unit 4 Unit 5 Unit 3 Unit 8 Unit 1 Unit 6 Unit 7 Unit 2
* Excludes 9 units with <6 new patients in 2006 with 50 - 100% AVFuse at commencement
Haemdialysis Access at First Dialysis: Top EightUnits in AVF Use (2006)
AVF AVGCatheter
0
11
89
7
0
93
8
0
92
10
3
87
10
0
90
11
2
87
15
3
83
15
7
78
0
20
40
60
80
100P
erce
ntag
e
Unit 1 Unit 2 Unit 3 Unit 4 Unit 5 Unit 6 Unit 7 Unit 8
* Excludes 10 units with <6 new patients in 2006 all with 100% CVCuse at commencement
Haemdialysis Access at First Dialysis: Bottom EightUnits in AVF Use (2006)
AVF AVGCatheter
23
8
69
33
0
67
33
6
61
38
0
63
38
13
50
44
0
56
45
0
55
83
0
17
0
20
40
60
80
Per
cent
age
Unit 1 Unit 2 Unit 3 Unit 4 Unit 5 Unit 6 Unit 7 Unit 8
* Excludes units commencing <6 new patients in 2006
Haemdialysis Access at First Dialysis: Units With 100% ofNew Patients Commenced on Haemodialysis (2006)
AVF AVG
Catheter
0
11
89
21
4
75
31
0
69
33
0
67
38
4
59
52
0
48
58
13
29
60
0
40
0
20
40
60
80
100P
erce
ntag
e
Unit 1 Unit 2 Unit 3 Unit 4 Unit 5 Unit 6 Unit 7 Unit 8
* Excludes units commencing <6 new patients in 2006
Haemdialysis Access at First Dialysis: Units With >40% ofNew Patients Commenced on Peritoneal Dialysis (2006)
AVF AVG
Catheter
Conclusions
• Catheter rates have increased significantly over the last 6 years
• Rates increased not just in incident patients but also prevalence patients
• Increased rates not accounted for by differences in comorbidity
• Trends has continued into 2006 and “similar for PD and HDx units”
Acknowledgements
• Dr Louise Moist• Dr Stephen MacDonald• Dr Sean Chang• ANZDATA Registry• Renal Units in Australia and New Zealand