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Author Notes:

Sophia V. Kazakova, MD, MPH, PhD, Division of Health Care Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE MS H16-3, Atlanta, GA 30329. srk7@cdc.gov

Research idea and study design: PRP, JAJ, JB, SVK; data analysis/interpretation: SVK, SHY, PRP, JB, DN, IWA; statistical analysis: SVK, SHY; supervision and mentorship: PRP, JB, JAJ. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that question pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. All authors approved submission of the manuscript to the journal.

The authors declare that they have no relevant financial interests.


Research Funding:

This work was supported through salary funds from the Division of Healthcare Quality Promotion of the CDC.


  • End-stage renal disease
  • arteriovenous fistula
  • arteriovenous graft
  • bacteremia
  • bloodstream infection
  • central venous catheter
  • hemodialysis
  • hemodialysis vascular access
  • septicemia

Vascular Access and Risk of Bloodstream Infection Among Older Incident Hemodialysis Patients


Journal Title:

Kidney Medicine


Volume 2, Number 3


, Pages 276-285

Type of Work:

Article | Final Publisher PDF


Rationale & Objective: Most new patients with end-stage renal disease (ESRD) initiate hemodialysis (HD) with a central venous catheter (CVC) and later transition to a permanent vascular access with lower infection risk. The benefit of early fistula use in preventing severe infections is incompletely understood. We examined patients’ first access and subsequent transitions between accesses during the first year of HD to estimate the risk for bloodstream infection (BSI) associated with incident and time-dependent use of HD access. Study Design: A retrospective cohort study using enhanced 5% Medicare claims data. Setting & Participants: New patients with ESRD initiating HD between January 1, 2011, and December 31, 2012, and having complete pre-ESRD Medicare fee-for-service coverage for 2 years. Exposure: The incident and prevalent use of CVC, graft, or fistula as determined from monthly reports to the Centers for Medicare & Medicaid Services by HD providers. Outcome: Incident hospitalization with a primary/secondary diagnosis of BSI (International Classification of Diseases, Ninth Revision, Clinical Modification code 038.xx or 790.7). Analytical Approach: Extended survival analysis accounting for patient confounders. Results: Of 2,352 study participants, 1,870 (79.5%), 77 (3.3%), and 405 (17.2%) initiated HD with a CVC, graft, and fistula, respectively. During the first year, the incident BSI hospitalization rates per 1,000 person-days were 1.3, 0.8, and 0.3 (P<0.001) in patients initiating with a CVC, graft, and fistula, respectively. After adjusting for confounders, incident fistula use was associated with 61% lower risk for BSI (HR, 0.39; 95% CI, 0.28-0.54; P<0.001) compared with incident CVC or graft use. The prevalent fistula or graft use was associated with lower risk for BSI compared with prevalent CVC use (HRs of 0.30 [95% CI, 0.22-0.42] and 0.47 [95% CI, 0.31-0.73], respectively). Limitations: Restricted to an elderly population; potential residual confounding. Conclusions: Incident fistula use was associated with lowest rates of BSI, but the majority of beneficiaries with pre-ESRD insurance initiated HD with a CVC. Strategies are needed to improve pre-ESRD fistula placement.

Copyright information:

© 2020 The Authors

This is an Open Access work distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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