What is the incidence of access-related complications in patients with end-stage renal disease (ESRD) undergoing dialysis?

Incidence of Access-Related Complications in Dialysis Patients

Vascular access complications are a major cause of morbidity in hemodialysis patients, with the USRDS reporting that hemodialysis access failure is the most frequent cause of hospitalization among ESRD patients. 1

Overall Complication Burden

• A high percentage of ESRD patient hospitalizations (up to 48-73%) are due to vascular access complications, making this the single most important factor determining dialysis treatment quality 1, 2
• Access complications represent a major source of both morbidity and mortality, with infectious complications being particularly problematic 3, 2
• All methods of dialysis access will eventually result in dysfunction and failure over time 1

Thrombosis Rates by Access Type

Arteriovenous Grafts (AVG)

• The target thrombosis rate should not exceed 0.5 thrombotic episodes per patient-year at risk 1
• The national average thrombosis rate for all permanent accesses is approximately 0.8 episodes per patient-year, with grafts likely exceeding this rate 1
• Access intervention rates for AVGs range from 91-158 per 100 patient-years 1

Arteriovenous Fistulas (AVF)

• After adjusting for initial failures (within first 2 months), the thrombosis rate should be less than 0.25 episodes per patient-year at risk 1
• Access intervention rates for AVFs range from 47-52 per 100 patient-years 1
• However, AVF failure to mature or nonusability occurs in 20-60% of cases, which should be considered a complication requiring interventions 1

Central Venous Catheters (CVC)

• Access loss rates are dramatically higher at 48-107 per 100 patient-years compared to AVF (2-14 per 100 patient-years) and AVG (11 per 100 patient-years) 1

Infection Rates by Access Type

Arteriovenous Fistulas (Lowest Risk)

• AVFs have the lowest infection rates at 1-4% local and bacteremic infections during their lifetime 4
• The relative risk of bacteremia with AVFs is 7 times lower than with catheters 4
• AVFs have 3-7 times fewer complication events than prosthetic grafts 4

Arteriovenous Grafts (Intermediate Risk)

• Infection rates of 11-20% during their expected usage period 4
• Prosthetic grafts are a recognized risk factor for both bacteremic and nonbacteremic infections 2

Tunneled Catheters (High Risk)

• Bacteremia rate of less than 5% at 3 months, but 50% removal due to infection at 1 year of use 4
• Infection rate of 1.6 per 1,000 catheter-days 4
• Systemic and local infections occur more frequently with cuffed catheters than with AV accesses 1

Non-Tunneled Catheters (Highest Risk)

• Infection incidence of less than 8% at 2 weeks, but increases exponentially with time 4
• Infection rate of 2.7 per 1,000 catheter-days 4

Additional Complications

Bloodstream Infections

• Bloodstream infections were significantly lower among patients starting HD with an AVF (6.4%) versus a CVC (15%) with hazard ratio of 0.28 1
• Vascular access is implicated in 48-73% of all bacteremias in hemodialysis patients 2

Central Venous Stenosis

• Chronic catheter access is associated with risk of central venous stenosis, which can preclude establishment of permanent vascular access 1

Inadequate Dialysis

• Cuffed catheters are associated with lower blood flow rates compared to AV access, which can compromise dialysis adequacy when treatment duration is not adjusted appropriately 1

Critical Clinical Pitfalls

• Up to 90% of accesses with abnormal physical examinations will have an underlying clinically significant finding on imaging, making routine monitoring essential 1
• Silent infection in old nonfunctional clotted prosthetic arteriovenous grafts is a frequently unrecognized cause of bacteremia 2
• The increased AVF creation rate has revealed a significant problem with maturation failure (20-60%), which requires unintended interventions including CVC insertion 1