Center-effect of incident hemodialysis vascular access use: Analysis of a bi-national registry

Background: Commencing hemodialysis (HD) with an arteriovenous access is associated with superior patient outcomes compared to a catheter but the majority of patients in Australia and New Zealand (ANZ) initiate HD with a central venous catheter. This study examined patient and center factors associated with arteriovenous fistula/graft access use at HD commencement. Methods: All adult patients starting chronic HD in Australia and New Zealand between 2004 and 2015 were included. Access type at HD initiation was analyzed using logistic regression. Patient-level factors included sex, age, race, body mass index (BMI), smoking status, primary kidney disease, late nephrologist referral, comorbidities and prior kidney replacement therapy (KRT). Center-level factors included size, transplant capability, home HD proportion, incident peritoneal dialysis (average number of patients commencing KRT with peritoneal dialysis per year), mean weekly HD hours, average blood flow and achievement of phosphate, hemoglobin and weekly Kt/V targets. The study included 27,123 patients from 61 centers. Results: Arteriovenous access use at HD commencement varied 4-fold from 15% to 62% (median 39%) across centers. Incident arteriovenous access use was more likely in patients aged 51-72 years, males and patients with BMI >25kg/m2 and polycystic kidney disease but less likely in patients with BMI