Arteriovenous graft placement in predialysis patients: a potential catheter-sparing strategy.

Background: When predialysis patients are deemed unsuitable candidates for an arteriovenous fistula, current guidelines recommend waiting until just before or after initiation of dialysis therapy before placing a graft. This strategy may increase catheter use when these patients start dialysis therapy. We compared the outcomes of patients whose grafts were placed before and after dialysis therapy initiation. Study Design: Retrospective analysis of a prospective computerized vascular access database. Setting & Participants: Patients with chronic kidney disease receiving their first arteriovenous graft (n = 248) at a large medical center. Predictor: Timing of graft placement (before or after initiation of dialysis therapy). Outcome & Measurements: Primary graft failure, cumulative graft survival, catheter dependence, and catheter-related bacteremia. Results: The first graft was placed predialysis in 62 patients and postdialysis in 186 patients. Primary graft failure was similar for pre- and postdialysis grafts (20% vs 24%; P = 0.5). Median cumulative graft survival was similar for pre-and postdialysis grafts (365 vs 414 days; HR, 1.22; 95% CI, 0.81-1.98; P = 0.3). Median duration of catheter dependence after graft placement in the postdialysis group was 48 days and was associated with 0.63 (95% CI, 0.48-0.79) episodes of catheter-related bacteremia per patient. Limitations: Retrospective analysis, single medical center. Conclusion: Grafts placed predialysis have primary failure rates and cumulative survival similar to those placed after starting dialysis therapy. However, postdialysis graft placement is associated with prolonged catheter dependence and frequent bacteremia. Predialysis graft placement may decrease catheter dependence and bacteremia in selected patients. Am J Kidney Dis. 58(2): 243-247. (C) 2011 by the National Kidney Foundation, Inc.