Forearm Versus Upper Arm Location of Arteriovenous Access Used at Hemodialysis Initiation: Temporal Trends and Racial Disparities.

Abstract

RATIONALE & OBJECTIVE Racial and ethnic differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated racial and ethnic differences in the use of an AVA in the forearm location at HD initiation. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Using records from DaVita Kidney Care linked to the United States Renal Data System (USRDS), we evaluated patients aged ≥16 years who initiated in-center HD with an AVA between 2006 and 2019. PREDICTOR Race/ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other. OUTCOME Forearm vs. upper arm AVA location. ANALYTICAL APPROACH Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and racial/ethnic differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of racial/ethnic differences. RESULTS Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease, but less likely to have diabetes compared to the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race/ethnicity by calendar year interaction P=0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA. LIMITATIONS Findings may not apply to home HD. CONCLUSIONS Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research towards understanding the causes and consequences of these trends and disparities is warranted.