IFT09 - Recent Evaluation by a Nephrologist Prior to First Arteriovenous Access Creation Is Associated with Less Tunneled Dialysis Catheter Placement

Objectives: Late primary care or nephrology evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing their first arteriovenous (AV) access creation, we aimed to evaluate the relationship of recent primary care provider (PCP) and nephrologist evaluation with perioperative morbidity and mortality.

Methods: We performed a single center retrospective review of patients from 2014-2022 who underwent initial AV access creation and were not candidates for peritoneal dialysis. We utilized univariable and multivariable analyses to identify associations of PCP evaluation < 1 year and nephrologist evaluation < 3 months of surgery with hemodialysis initiation via tunneled dialysis catheters (TDC), 90-day readmission, and 90-day mortality.

Results: Among 558 patients receiving initial AV access, mean age was 59.7±14 years, 59% were female sex, and 60.6% were black. Evaluation by PCPs < 1 year and nephrologists < 3 months of surgery occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured status was associated with decreased likelihood of PCP evaluation (unemployment: OR 0.51, 95% CI 0.34-0.77; uninsured status: OR .05, 95% CI 0.01-0.45) and nephrologist evaluation (unemployment: OR 0.63, 95% CI 0.43-0.91; uninsured status: OR 0.22, 95% CI 0.06-0.83), while social support was associated with increased likelihood of PCP evaluation (OR 1.81, 95% CI 1.07-3.08) (all P<.05). Hemodialysis was initiated with TDCs in 304 (55%) patients. Older age (OR 0.98, 95% CI 0.96-0.99), obesity (OR 0.38, 95% CI 0.25-0.58), and nephrologist evaluation (OR 0.12, 95% CI 0.08-0.19) were independently associated with decreased hemodialysis initiation with TDCs (all P<.05). Readmission occurred in 270 (48%) cases. Cirrhosis (OR 2.5, 95% CI 1.03-6.03, P=.04), coronary artery disease (OR 2.31, 95% CI 1.5-3.57), prosthetic AV access (OR 1.84, 95% CI 1.04-3.26), and impaired ambulation (OR 1.75, 95% CI 1.15-2.66) were independently associated with increased readmission, while older age (OR 0.98, 95% CI 0.97-.99), prior TDC (OR 0.65, 95% CI 0.45-0.94, P=.02), and unemployment (OR 0.58, 95% CI 0.39-0.86) were associated with decreased readmission (all P<.05). Mortality occurred in 9 (1.6%) patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality.

Conclusions: Recent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients receiving initial AV access creation. Unemployed and uninsured status poses barriers to accessing nephrology care.