Vascular Access Type, Inflammatory Markers, and Mortality in Incident Hemodialysis Patients: The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study

• Published in: American journal of kidney diseases Vol. 64; no. 6; pp. 954 - 961
• Main Authors: Banerjee, Tanushree, Kim, S. Joseph, Astor, Brad, Shafi, Tariq, Coresh, Josef, Powe, Neil R.
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.12.2014; Elsevier
• Subjects: access failure; access patency; Adult; Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Arteriovenous Shunt, Surgical - mortality; Arteriovenous Shunt, Surgical - trends; Biological and medical sciences; biomarker; Biomarkers - blood; C-reactive protein (CRP); Catheterization, Central Venous - mortality; Catheterization, Central Venous - trends; central venous catheter (CVC); Choice Behavior; Cohort Studies; Cox proportional hazard model; Emergency and intensive care: renal failure. Dialysis management; end-stage renal disease (ESRD); Female; hemodialysis; Humans; Incidence; inflammation; Inflammation Mediators - blood; Intensive care medicine; interleukin 6 (IL-6); Kidney Failure, Chronic - blood; Kidney Failure, Chronic - mortality; Kidney Failure, Chronic - therapy; Longitudinal Studies; Male; Medical sciences; Middle Aged; mixed-effects model; Mortality - trends; Nephrology; Nephrology. Urinary tract diseases; Nephropathies. Renovascular diseases. Renal failure; Patient Care - mortality; Patient Care - trends; Prospective Studies; Renal Dialysis - mortality; Renal Dialysis - trends; Renal failure; Treatment Outcome; vascular access type; access failure; access patency; mixed-effects model; inflammation; end-stage renal disease (ESRD); interleukin 6 (IL-6); hemodialysis; C-reactive protein (CRP); Cox proportional hazard model; vascular access type; biomarker; central venous catheter (CVC); Venous access; Nephrology; Choice; Prognosis; Intravenous administration; Chronic renal failure; Accessibility; Hemodialysis; Biological marker; Injection site; Epidemiology; Incidence; Interleukin 6; Extrarenal dialysis; C reactive protein; Failure; Hazard; Kidney disease; Human; Urinary system disease; Healthy subject; Mortality; Cytokine; Biological indicator; Terminal stage; Inflammation; Central vein; Acute phase protein; Cox model; Mixed; Renal failure
• ISSN: 0272-6386; 1523-6838; 1523-6838
• DOI: 10.1053/j.ajkd.2014.07.010

Few reports have shown an association between access type and inflammatory marker levels in a longitudinal cohort. We investigated the role of access type on serial levels of inflammatory markers and the role of inflammatory markers in mediating the association of access type and risk of mortality in a prospective study of incident dialysis patients. Cohort study, post hoc analysis of the CHOICE (Choices for Healthy Outcomes in Caring for ESRD) Study. In 583 participants, inflammation was assessed by measuring serum C-reactive protein (CRP) and interleukin 6 (IL-6) after access placement and at multiple times during 3 years’ follow-up. Type of access was categorized as central venous catheter (CVC), arteriovenous graft (AVG), and arteriovenous fistula (AVF), and changes over time were recorded. Access type, age, sex, race, body mass index, diabetes, cardiovascular disease, and serum albumin level. CRP level, IL-6 level, and mortality. We used mixed-effects pattern mixture models to study the association between access type and repeated measurements of inflammation and survival analysis to investigate the association of access type and mortality, adjusting for predictors. In a mixed-effects pattern mixture model, compared with AVFs, the presence of CVCs and AVGs was associated with 62% (P=0.02) and 30% (P=0.05) increases in average CRP levels, respectively. A Cox proportional hazards model yielded nonsignificant associations of CVC and AVG use (vs AVFs) with risk of mortality when adjusted for inflammatory marker levels. Higher CRP levels were associated with increased risk of CVC failure than lower CRP levels. CRP and IL-6 measurements not performed for all hemodialysis patients. CVCs, compared with AVFs, are associated with a greater state of inflammation in incident hemodialysis patients, and the association of catheter use and mortality may be mediated by access-induced inflammation. Our findings support recommendations for the early removal or avoidance of CVC placements.