haemodialysis vascular access: recent trends from anzdata dr kevan polkinghorne monash medical...

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