American Journal of Kidney Diseases

Facility Hemodialysis Vascular Access Use and Mortality in Countries Participating in DOPPS: An Instrumental Variable Analysis

Published:January 16, 2009DOI:


      Previously, the Dialysis Outcomes and Practice Patterns Study (DOPPS) has shown large international variations in vascular access practice. Greater mortality risks have been seen for hemodialysis (HD) patients dialyzing with a catheter or graft versus a native arteriovenous fistula (AVF). To further understand the relationship between vascular access practice and outcomes, we have applied practice-based analyses (using an instrumental variable approach) to decrease the treatment-by-indication bias of prior patient-level analyses.

      Study Design

      A prospective observational study of HD practices.

      Setting & Participants

      Data collected from 1996 to 2004 from 28,196 HD patients from more than 300 dialysis units participating in the DOPPS in 12 countries.

      Predictor or Factor

      Patient-level or case-mix–adjusted facility-level vascular access use.


      Mortality and hospitalization risks.


      After adjusting for demographics, comorbid conditions, and laboratory values, greater mortality risk was seen for patients using a catheter (relative risk, 1.32; 95% confidence interval, 1.22 to 1.42; P < 0.001) or graft (relative risk, 1.15; 95% confidence interval, 1.06 to 1.25; P < 0.001) versus an AVF. Every 20% greater case-mix–adjusted catheter use within a facility was associated with 20% greater mortality risk (versus facility AVF use, P < 0.001); and every 20% greater facility graft use was associated with 9% greater mortality risk (P < 0.001). Greater facility catheter and graft use were both associated with greater all-cause and infection-related hospitalization. Catheter and graft use were greater in the United States than in Japan and many European countries. More than half the 36% to 43% greater case-mix–adjusted mortality risk for HD patients in the United States versus the 5 European countries from the DOPPS I and II was attributable to differences in vascular access practice, even after adjusting for other HD practices. Vascular access practice differences accounted for nearly 30% of the greater US mortality compared with Japan.


      Possible existence of unmeasured facility- and patient-level confounders that could impact the relationship of vascular access use with outcomes.


      Facility-based analyses diminish treatment-by-indication bias and suggest that less catheter and graft use improves patient survival.

      Index Words

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      1. Kidney Disease: Improving Global Outcomes (KDIGO).
        (Accessed September 25, 2007)
        • Tordoir J.
        • Canaud B.
        • Haage P.
        • et al.
        EBPG on vascular access.
        Nephrol Dial Transplant. 2007; 22: Sii88-Sii117
        • Mactier R.
        The Renal Association Clinical Practice Guidelines.
        (Accessed October 10, 2007)
        • Centers for Medicare & Medicaid Services
        2006 Annual Report, End Stage Renal Disease Clinical Performance Measures Project.
        Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Clinical Standards & Quality, Baltimore, MD2007
        • Pisoni R.L.
        • Young E.W.
        • Dykstra D.M.
        • et al.
        Vascular access use in Europe and the United States: Results from the DOPPS.
        Kidney Int. 2002; 61: 305-316
        • Pisoni R.L.
        • Young E.W.
        • Mapes D.L.
        • Keen M.L.
        • Port F.K.
        Vascular access use and outcomes in the U.S., Europe, and Japan: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS).
        Nephrol News Issues. 2003; 17: 38-47
        • Combe C.H.
        • Pisoni R.L.
        • Port F.K.
        • et al.
        Dialysis Outcomes and Practice Patterns Study: Données sur l'utilisation des cathéters veineux centraux en hémodialyse chronique.
        Nephrologie. 2001; 22: 379-384
        • Dhingra R.K.
        • Young E.W.
        • Hulbert-Shearon T.E.
        • et al.
        Type of vascular access and mortality in US hemodialysis patients.
        Kidney Int. 2001; 60: 1443-1451
        • Pastan S.
        • Soucie J.M.
        • McClellan W.M.
        Vascular access and increased risk of death among hemodialysis patients.
        Kidney Int. 2002; 62: 620-626
        • Xue J.L.
        • Dahl D.
        • Ebben J.P.
        • Collins A.J.
        The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients.
        Am J Kidney Dis. 2003; 42: 1013-1019
        • Polkinghorne K.R.
        • McDonald S.P.
        • Atkins R.C.
        • Kerr P.G.
        Vascular access and all-cause mortality: A propensity score analysis.
        J Am Soc Nephrol. 2004; 15: 477-486
        • Astor B.C.
        • Eustace J.A.
        • Powe N.R.
        • Klag M.J.
        • Fink N.E.
        • Coresh J.
        CHOICE Study: Type of vascular access and survival among incident hemodialysis patients: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study.
        J Am Soc Nephrol. 2005; 16: 1449-1455
        • Allon M.
        • Daugirdas J.
        • Depner T.A.
        • Greene T.
        • Ornt D.
        • Schwab S.J.
        Effect of change in vascular access on patient mortality in hemodialysis patients.
        Am J Kidney Dis. 2006; 47: 469-477
        • Thomson P.C.
        • Stirling C.M.
        • Geddes C.C.
        • Morris S.T.
        • Mactier R.A.
        Vascular access in haemodialysis patients: A modifiable risk factor for bacteraemia and death.
        QJM. 2007; 100: 415-422
        • Bradbury B.D.
        • Fissell R.B.
        • Albert J.M.
        • et al.
        Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
        Clin J Am Soc Nephrol. 2007; 2: 89-99
        • Schneeweiss S.
        • Solomon D.H.
        • Wang P.S.
        • Rassen J.
        • Brookhart M.A.
        Simultaneous assessment of short-term gastrointestinal benefits and cardiovascular risks of selective cyclooxygenase 2 inhibitors and nonselective nonsteroidal antiinflammatory drugs: An instrumental variable analysis.
        Arthritis Rheum. 2006; 54: 3390-3398
        • Brookhart M.A.
        • Wang P.S.
        • Solomon D.H.
        • Schneeweiss S.
        Evaluating short-term drug effects using a physician-specific prescribing preference as an instrumental variable.
        Epidemiology. 2006; 17: 268-275
        • Brooks J.M.
        • Irwin C.P.
        • Hunsicker L.G.
        • Flanigan M.J.
        • Chrischilles E.A.
        • Pendergast J.F.
        Effect of dialysis center profit-status on patient survival: A comparison of risk-adjustment and instrumental variable approaches.
        Health Services Res. 2006; 41: 2267-2289
        • Stukel T.A.
        • Fisher E.S.
        • Wennberg D.E.
        • Alter D.A.
        • Gottlieb D.J.
        • Vermeulen M.J.
        Analysis of observational studies in the presence of treatment selection bias.
        JAMA. 2007; 297: 278-285
        • Angrist J.D.
        • Imbens G.W.
        Two-stage least squares estimation of average causal effects in models with variable treatment intensity.
        J Am Stat Assoc. 1995; 90: 431-442
        • Johnston S.C.
        Combining ecological and individual variables to reduce confounding by indication: Case study—Subarachnoid hemorrhage treatment.
        J Clin Epidemiol. 2000; 53: 1236-1241
        • Young E.W.
        • Goodkin D.A.
        • Mapes D.L.
        • et al.
        The Dialysis Outcomes and Practice Patterns Study (DOPPS): An international hemodialysis study.
        Kidney Int Suppl. 2000; 74: S74-S81
        • Pisoni R.L.
        • Gillespie B.W.
        • Dickinson D.M.
        • Chen K.
        • Kutner M.
        • Wolfe R.A.
        The Dialysis Outcomes and Practice Patterns Study: Design, data elements, and methodology.
        Am J Kidney Dis. 2004; 44: S7-S15
        • Klein J.
        • Moeschberger M.
        Survival Analysis Techniques for Censored and Truncated Data.
        in: Springer, New York, NY1997: 416-418
        • Johnston J.
        • DiNardo J.
        Econometric Methods.
        (ed 4). McGraw Hill, New York, NY1998
        • Hoen B.
        • Paul-Dauphin A.
        • Hestin D.
        • Kessler M.
        EPIBACDIAL: A multicenter retrospective study of risk factors for bacteremia in chronic hemodialysis patients.
        J Am Soc Nephrol. 1998; 9: 869-876
        • Powe N.R.
        • Jaar B.
        • Furth S.L.
        • Hermann J.
        • Briggs W.
        Septicemia in dialysis patients: Incidence, risk factors, and prognosis.
        Kidney Int. 1999; 55: 1081-1090
        • Jean G.
        • Charra B.
        • Chazot C.
        • et al.
        Risk factor analysis for long-term tunneled dialysis catheter-related bacteremias.
        Nephron. 2002; 91: 399-405
        • Stevenson K.B.
        • Adcox M.J.
        • Mallea M.C.
        • Narasimhan N.
        • Wagnild J.P.
        Standardized surveillance of hemodialysis vascular access infections: 18-Month experience at an outpatient, multifacility hemodialysis center.
        Infect Control Hosp Epidemiol. 2000; 21: 200-203
        • Gulati S.
        • Sahu K.M.
        • Avula S.
        • Sharma R.K.
        • Ayyagiri A.
        • Pandey C.M.
        Role of vascular access as a risk factor for infections in hemodialysis.
        Ren Fail. 2003; 25: 967-973
        • George A.
        • Tokars J.I.
        • Clutterbuck E.J.
        • Bamford K.B.
        • Pusey C.
        • Holmes A.H.
        Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: Prospective study.
        BMJ. 2006; 332: 1435
        • Troidle L.
        • Eisen T.
        • Pacelli L.
        • Finkelstein F.
        Complications associated with the development of bacteremia with Staphylococcus aureus.
        Hemodial Int. 2007; 11: 72-75
        • Inrig J.K.
        • Reed S.D.
        • Szczech L.A.
        • et al.
        Relationship between clinical outcomes and vascular access type among hemodialysis patients with Staphylococcus aureus bacteremia.
        Clin J Am Soc Nephrol. 2006; 1: 518-524
        • Ishani A.
        • Collins A.J.
        • Herzog C.A.
        • Foley R.N.
        Septicemia, access and cardiovascular disease in dialysis patients: The USRDS Wave 2 Study.
        Kidney Int. 2005; 68: 311-318
        • Greenland S.
        An introduction to instrumental variables for epidemiologists.
        Int J Epidemiol. 2000; 29: 722-729
        • Newhouse J.P.
        • McClellan M.
        Econometrics in outcomes research: The use of instrumental variables.
        Annu Rev Public Health. 1998; 19: 17-34
        • Wolfe R.A.
        • Hulbert-Shearon T.E.
        • Ashby V.B.
        • Messana J.M.
        Decreases in catheter use are associated with decreases in mortality for dialysis facilities during 2000-03.
        J Am Soc Nephrol. 2005; 16 (abstr): 95A
        • Ethier J.
        • Mendelssohn D.C.
        • Elder S.J.
        • et al.
        Vascular access use and outcomes: An international perspective: Results from the Dialysis Outcomes and Practice Patterns Study.
        Nephrol Dial Transplant. 2008; 23: 3219-3226
        • Sands J.J.
        Increasing AV fistulae and decreasing dialysis catheters: Two aspects of improving patient outcomes.
        Blood Purif. 2007; 25: 99-102
        • Lacson Jr, E.
        • Lazarus J.M.
        • Himmelfarb J.
        • Ikizler T.A.
        • Hakim R.M.
        Balancing Fistula First with catheters last.
        Am J Kidney Dis. 2007; 50: 379-395
        • Engemann J.J.
        • Friedman J.Y.
        • Reed S.D.
        • et al.
        Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis.
        Infect Control Hosp Epidemiol. 2005; 26: 534-539
        • Greenwood R.N.
        • Ronco C.
        • Gastaldon F.
        • et al.
        Erythropoietin dose variation in different facilities in different countries and its relationship to drug resistance.
        Kidney Int Suppl. 2003; 87: S78-S86
        • Roberts T.L.
        • Obrador G.T.
        • St Peter W.L.
        • Pereira B.J.
        • Collins A.J.
        Relationship among catheter insertions, vascular access infections, and anemia management in hemodialysis patients.
        Kidney Int. 2004; 66: 2429-2436
        • Kaysen G.A.
        • Kumar V.
        Inflammation in ESRD: Causes and potential consequences.
        J Ren Nutr. 2003; 13: 158-160
        • Pisoni R.L.
        • Bragg-Gresham J.L.
        • Young E.W.
        • et al.
        Anemia management outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
        Am J Kidney Dis. 2004; 44: 94-111
        • Yoshino M.
        • Kuhlmann M.K.
        • Greenwood R.N.
        • et al.
        International differences in dialysis mortality reflect background general population atherosclerotic cardiovascular mortality.
        J Am Soc Nephrol. 2006; 17: 3510-3519

      Linked Article

      • Vascular Access Practice in Hemodialysis: Instrumental in Determining Patient Mortality
        American Journal of Kidney DiseasesVol. 53Issue 3
        • Preview
          Important epidemiological studies and findings often arise from very simple clinical observations. In a letter to Nephrology Dialysis and Transplantation in 1997, de Almeida and colleagues1 noted reduced survival in hemodialysis patients who required more than 1 vascular access over a period of 2.5 years of follow up. This short letter was (unusually) accompanied by an editorial comment by Woods and Port broadening the hypothesis and suggesting that commencing hemodialysis without permanent vascular access could be associated with increased patient morbidity and possibly mortality via an increased risk of infection and the delivery of a lower dialysis dose.
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