Vascular Access Type and Patient and Technique Survival in Home Hemodialysis Patients: The Canadian Organ Replacement Register

Background While central venous catheter (CVC) use has expanded home hemodialysis (HHD) eligibility to many patients who may be unable to self-cannulate an arteriovenous (AV) access, the association between CVC use and mortality has not been directly examined among HHD patients. Study Design Registry-based retrospective observational cohort study. Setting & Participants Incident HHD patients in The Canadian Organ Replacement Register who had information for vascular access type (CVC vs AV access) within the first year of HHD therapy initiation. Predictor Use of a CVC versus an AV access (AV fistula or graft) within the first year of HHD therapy initiation. Outcome The composite of all-cause mortality and technique failure (long-term transfer to an alternate dialysis modality). A Cox proportional hazards model was used to evaluate the adjusted composite outcome and each outcome separately. Results 1,869 patients initiated HHD therapy in Canada in 1996 to 2012, of whom 1,217 had an access type recorded within the first year of HHD therapy initiation. Compared to CVC use (n = 523) and during a median follow-up of 513 and 427 days for AV access and CVC patients, respectively, AV access use (n = 694) was associated with lower risk for the composite event of death and technique failure (490 events; adjusted HR, 0.78; 95% CI, 0.64-0.94) and lower adjusted all-cause mortality (129 deaths; adjusted HR, 0.63; 95% CI, 0.43-0.91); the risk for technique failure was nominally lower, but this result was not statistically significant (361 events; adjusted HR, 0.84; 95% CI, 0.67-1.05). Results were robust to sensitivity analyses and after missing data imputation. Limitations Missing information for vascular access type (n = 659 [35% of patients]) and lack of information for longitudinal changes in vascular access type. Conclusions Compared to CVC use, AV access use was associated with superior survival. Minimizing CVC use and maximizing AV access use while addressing barriers to their placement and self-cannulation may improve HHD outcomes.