Effects of Racial Bias in First Time Vascular Access for Hemodialysis
Nina A Moiseiwitsch, Sydney Browder, Katharine McGinigle, Jacob Wood, William Marston, Mark A Farber, F. Ezequiel Parodi, Luigi Pascarella
UNC-Chapel Hill School of Medicine, Division of Vascular Surgery, Chapel Hill, NC
INTRODUCTION: Hemodialysis Central Venous Catheters (HD-CVCs) pose a greater risk of infection and life-threatening complications than either arteriovenous fistula (AVF) or arteriovenous graft (AVG). Nonetheless, most patients in the US with newly diagnosed end-stage renal disease (ESRD) initiate kidney replacement therapy via HD-CVC. Late referral to vascular surgery and nephrology are known problems contributing to HD-CVC days. There may also be disparities in race and ethnicity in health provision and outcomes among newly-diagnosed ESRD patients. The objective of this study was to identify the association of race/ethnicity and first hemodialysis access type.
METHODS: Adult patients diagnosed with ESRD in 2015-2020 were extracted from an electronic health record database in our healthcare system. Pertinent demographic data and procedures for hemodialysis access creation (HD-CVC, AVF, or AVG) were collected. The primary outcome was all-cause mortality at 6 months, 1 year, and 2 years. Secondary outcomes include number of hospital days, time between ESRD diagnosis and first vascular access surgery, progression to AVF surgery, time from ESRD diagnosis to AVF surgery, and kidney transplant. Adjusted generalized linear models were used to estimate the risk of mortality by first access at each time point and modification by race/ethnicity was assessed. Risk ratios were calculated using HD-CVC as the reference group. Models were adjusted for age, sex, and race/ethnicity.
RESULTS: The final cohort included 6,290 patients with a mean age of 64.3 ± 14.7 and was 44.0% female, 40.5% non-Hispanic (NH) White, 49.8% NH Black, 3.8% NH other, and 6.0% Hispanic. Most patients received CVC as their first access type (54%), followed by AVF (39.0%) and AVG (7.0%). Compared to Whites, Black patients were less likely to receive an AVF as their first access type (36.2% vs 42.3%, p<0.0001). On average, HD-CVC patients spent significantly more days in the hospital (Table 2). Within 6 months of ESRD diagnosis, HD-CVC patients were 2.72 times more likely to die than either AVG or AVF patients (p<0.0001, Table 1). Increased mortality among HD-CVC patients persisted at 1 and 2 years (Table 1). White patients waited less time between ESRD diagnosis and first attempt at access placement than their Black counterparts whether their first access was a CVC or an AVF (p<0.0001 and p=0.0002, respectively). Of HD-CVC patients, White patients were more likely to receive an attempt to create AVF and waited less time after ESRD diagnosis for an attempt to be made compared to Black patients (p<0.0001 for both).
CONCLUSIONS: The study demonstrates an association between race and the provision of guideline-based care for patients with newly-diagnosed ESRD. With special focus on Black patients, we must advocate for an increased awareness among healthcare professionals of strategies for kidney replacement therapy and earlier referrals to nephrologists and vascular surgeons.
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