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

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 Patients on dialysis 6-8 months after commencement 2000, 2001, 2002, & 2003 All patients on haemodialysis 2000, 2002, 2004, & 2005

(2) 6-8 Month Cohort:

(3) Prevalent Cohort:

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

Variable Number of patients Age years % Men Race % White Indigenous Other Body Mass Index % Underweight Normal Overweight Obese

2000 448 62.5 81 10.5 8.5 5.8 43.8 32.1 18.2

2002 477 61 80.5 10.5 9 3.6 38.8 35.8 22.3

2004 487

P value 0.33 0.89 0.95

62.7 (47-72) 62.2 (49-73) 62.5 (51-74) 62 79 11.7 9.2 4.5 34.9 34.5 26.1

0.02

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

Variable Late Referral Ever Smoked Cause of ESRD Glomerulonephritis Diabetes mellitus Hypertension Other Co morbidities Diabetes Coronary artery disease Peripheral vascular disease Cerebrovascular disease Hypertension

2000 25 52.5 32.6 16.5 12.5 38.4 25.5 36.8 23.2 13.8 87.5

2002 28.1 51.2 27.5 26.6 14.7 31.2 37.7 39.4 25.6 13.8 89.7

2004 33.9 52.4 23.2 25.2 12.1 32.8 42.5 42.7 26.5 16 88.9

P value 0.01 0.93 <0.001

<0.001 0.18 0.49 0.54 0.6

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

Vascular Access: Incident Cohort 2000 -2004

100 80

39

43 53

Percentage

60

6 6 3

CVC AVG AVF

40

56
20

50

43

2000

2002

2004

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

Unadjusted & Adjusted Incident Rates: Incident Cohort 2000 - 2004

Incident Cohorts AVF/AVG CVC Unadjusted Adjusted Unadjusted Adjusted 61.4 59.5 38.6 40.5 56.9 57.7 43.1 42.3 46.9* 47.8* 53.1* 52.2*

2000 2002 2004

N 342 401 446

*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
100

10
80

16 15

19 9

22

12 11
CVC AVG AVF

Percentage

40

60

78 69

73

67

20

2000

2001

2002

2003

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

Unadjusted & Adjusted Incident Rates: 6-8 Months After Starting Dialysis 2000 - 2004
N 314 367 372 424 AVF/AVG CVC Unadjusted Adjusted Unadjusted Adjusted 89.8 90.8 10.2 9.2 83.9 86.1 16.1 13.9* 81.2 83.6 18.8* 16.2* 77.6 77.6 22.4* 20.0*

2000 2001 2002 2003

*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

80 100

59
Percentage 60

62

63
CVC AVG AVF

40

20

38

35

35

2003

2004

2005

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

18-30 years >30 years Caucasoid ATSI Other GN DM HT other Earlyl Late No Yes No Yes No Yes No Yes No Yes No Yes

Age (per 10 years) * Race Cause of ESRD

Referral * Smoker Diabetes Cardiovascular dis * Peripheral vascular dis Cerebrovascular dis Hypertension .25 .5 .67 1 1.5 2 Odds ratio 4

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

Prevalent Vascular Access 2000-2005

100

6 18

9 17

13 14

13 12

Percentage

60

80

CVC AVG AVF

40

75

74

73

74

20

2000

2002

2004

2005

Moist L, Chang S, Polkinghorne K, McDonald S. In Press Am J Kidney Diseases

2006 Data

Haemdialysis Access at First Dialysis (2006)

64

60

40
33

20

0
AVF Catheter AVG

* Excludes 22 Units with <6 New Patients in 2006

Haemdialysis Access at First Dialysis: Top Eight Units in AVF Use (2006)
83

80
65

60
50 42

56 52 48 44

56

58

60

41

40
29

40 35

20
8

17 13 2

Unit 4

Unit 5

Unit 3

Unit 8 AVF Catheter

Unit 1

Unit 6 AVG

Unit 7

Unit 2

* Excludes 9 units with <6 new patients in 2006 with 50 - 100% AVF use at commencement

Haemdialysis Access at First Dialysis: Bottom Eight Units in AVF Use (2006)
100
89 93 92 87 90 87 83 78

80 60 40 20 0
0 15 2 3 15 7

11 7 0

8 0

10 3

10 0

11

Unit 1

Unit 2

Unit 3

Unit 4 AVF Catheter

Unit 5

Unit 6 AVG

Unit 7

Unit 8

* Excludes 10 units with <6 new patients in 2006 all with 100% CVC use at commencement

Haemdialysis Access at First Dialysis: Units With 100% of New Patients Commenced on Haemodialysis (2006)
83

80
69 67 61 63 56 50 44 45 55

60
38 33 23 33 38

40

20
8 6 0 0

17 13

Unit 1

Unit 2

Unit 3

Unit 4 AVF Catheter

Unit 5

Unit 6 AVG

Unit 7

Unit 8

* Excludes units commencing <6 new patients in 2006

Haemdialysis Access at First Dialysis: Units With >40% of New Patients Commenced on Peritoneal Dialysis (2006)
100
89

80 60 40
21

75 69 67 59 52 48 38 31 33 29 40 58 60

20 0
0

11 4 0 0 4 0

13 0

Unit 1

Unit 2

Unit 3

Unit 4 AVF Catheter

Unit 5

Unit 6 AVG

Unit 7

Unit 8

* Excludes units commencing <6 new patients in 2006

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