The Impact of Peripherally-inserted Central Catheters and Vascular Imaging on Hemodialysis Patients.
Vascular access is a critical determinant of the survival of patients receiving
hemodialysis. A working fistula or a graft avoids risks of infection, hospitalization
and death that are associated with central venous hemodialysis catheter access. Adequate
blood vessels are required for creation of arteriovenous fistulas and grafts. Little is
known about the effect of strategies ... read moreto manage and preserve veins on the ability to
achieve vascular access for hemodialysis. This study defines the epidemiology of two
common medical procedures that may influence the likelihood that a patient will
transition to a fistula or graft: peripherally inserted central catheters, and vascular
imaging procedures. We examined these exposures in Medicare beneficiaries who initiated
hemodialysis with central venous catheters, and used proportional hazards models with
and without time dependent covariates to determine the associations of these exposures
with time to transition to first working arteriovenous fistulas or grafts and patient
survival. We found that one in every eight patients had been exposed to peripherally
inserted central catheters, after having initiated hemodialysis or during the two years
prior. Pre-dialysis exposure to PICC was associated with a decreased likelihood of
achieving a working arteriovenous fistula (HR=0.78, 95% CI=0.71, 0.85) or any fistula or
graft (HR=0.85, 95% CI=0.79, 0.91). Post-dialysis exposure to PICC was independently
associated with decreased achievement of working arteriovenous fistula (HR=0.81, 95%
CI=0.72, 0.90) or any fistula or graft (HR=0.81, 95% CI 0.73, 0.89). Fewer than 10% of
patients had diagnostic vascular imaging prior to initiating hemodialysis, despite
exposure to pre-dialysis nephrology care in nearly half. Vascular imaging performed
prior to dialysis initiation was associated with increased transition to arteriovenous
fistulas (HR=1.36, 95% CI=1.27, 1.45) and any arteriovenous fistula or graft (HR=1.57,
95% CI=1.49, 1.66). Imaging performed after hemodialysis treatments were initiated was
independently associated with increased working fistulas (HR=1.45, 95% CI=1.40, 1.51)
and transition to any working fistula or graft (HR=1.63, 95% CI=1.58, 1.69).
Approximately 70% of patients who have surgery achieve a fistula or graft, regardless of
whether imaging is employed, suggesting that the benefits are mediated by increased
performance of surgery in imaged patients. Our analyses suggest that peripherally
inserted central catheters are common and associated with poor outcomes. Vascular
imaging is infrequent, but associated with desireable outcomes. Decisions made regarding
the use of either of these procedures represent potentially modifiable practice patterns
that could influence dialysis outcomes.
Thesis (M.S.)--Tufts University, 2016.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: Daniel Weiner.
Committee: Eduardo Lacson, Robin Ruthazer, Klemens Meyer, and Dana Miskulin.
Keywords: Medicine, Biostatistics, and Epidemiology.read less
- Component ID:
- To Cite:
- TARC Citation Guide EndNote