Change in vascular access and mortality in maintenance hemodialysis XXXX .

@entity1 @entity292 @entity204 @entity6
BACKGROUND: We hypothesized that a change from central venous catheters to a @entity292 or graft would improve short-term mortality risk in maintenance hemodialysis @entity1 . DESIGN: Prospective observational study. SETTING _ @entity1 : All maintenance in-center hemodialysis @entity1 treated in Fresenius Medical Care, North America legacy facilities alive on January 1, 2007 with baseline laboratory data from December 2006. PREDICTOR: Access type ( @entity292 , catheter, or graft), determined on December 31, 2006, and monthly thereafter. Conversion from a catheter to a @entity292 or graft during the 4-month period from January 1 to April 30, 2007. OUTCOME: Mortality was tracked from May 1, 2007, to December 31, 2007. Standard and time-dependent Cox models were used to determine hazard risks (HRs) of @entity204 with and without adjustment for case-mix and laboratory values. RESULTS: At baseline, 79,545 @entity1 had 43% @entity292 , 29% catheters, and 27% grafts. Mean age was 62 +/- 15 years, 54% were @entity1 , 51% were white, and 53% had @entity6 . Compared with @entity292 , unadjusted HRs of @entity204 were higher for grafts (1.22) and catheters (1.76; P < 0.001). In adjusted models, overall risk for grafts was decreased to 1.05 (95% limits, 1.003-1.100; P < 0.05) and approached that for @entity292 consistently across multiple strata. Compared with @entity1 who continued using a catheter, those who converted to either a graft or @entity292 had an HR of 0.69, whereas those who converted from a graft or @entity292 to a catheter had increased HRs to 2.12 (both P < 0.001). Similar trends were observed in the subset of incident @entity1 (vintage < 90 days at study onset). LIMITATIONS: Observational design with residual confounding from unmeasured @entity1 , facility, and treatment-related factors. CONCLUSIONS: Catheters have the worst associated mortality risk. Changing from a catheter to a @entity292 or graft is associated with significantly improved survival. The risk for grafts approached that of @entity292 , providing an alternative to prolonged catheter exposure and potentially less hazardous "bridge" toward a @entity292 .
