Highlights There has been virtually no improvement in central venous catheter ("catheter") use at initiation of hemodialysis (HD) over the last decade, with catheter use declining only from 82.4% in 2009 to 80.8% in 2018 (Figure 3.1). In fact, initiation of HD with a catheter without a maturing arteriovenous (AV) fistula or graft increased from 60.2% of incident patients in 2013 to 65.2% of incident patients in 2018. Use of an AV fistula at HD initiation varied considerably by duration of pre-end stage renal disease (ESRD) care by a nephrologist (Figure 3.2). Use of an AV fistula occurred in 29.7% of patients with more than a year of prior nephrology care but in only 5.1% in patients with no or unknown prior nephrology care. Initiation of HD using a catheter without presence of a maturing AV fistula or graft demonstrated substantial geographic variability, occurring most frequently (in more than 70% of patients) in OK, AR, IL, NV, WV, and TX, and least frequently (in less than 52% of patients) in NH, UT, WA, VT, and HI (Figure 3.3). States with the highest unadjusted percentage of patients initiating HD with a fistula (more than 30% of patients) were ME, HI, and VT, whereas states with the lowest percentages (less than 13% of patients) were GA, FL, and TX. Among prevalent patients as of December 2018, more than four out of every five patients receiving HD were using an AV fistula or graft (82.4%; 65.7% fistula and 16.7% graft) (Figure 3.4). Among prevalent patients receiving HD as of December 2018, catheter use was highest in MT (24.5%), VT (27.0%), and WV (27.5%) and lowest in HI (14.9%), RI (14.9%), and KS (14.8%) (Figure 3.5). Conversely, AV fistula use was lowest in WV (57.7%), SC (57.0%), and AL (56.7%) and highest in CO (73.0%), AK (73.8%), and UT (74.6%). Among patients initiating HD in 2017 who were followed for up to 18 months and remained on HD, 80.1% initiated dialysis using a catheter, 16.8% an AV fistula, and 3.1% an AV graft. More than 68% of patients were still using a catheter by 3 months after initiation (Figure 3.7a). Only by 6 months after HD initiation did a majority of patients use an AV access. By 18 months after HD initiation, 85.1% of patients were using an AV access. Among all patients initiating HD in 2017 (including those who did not remain on HD), within 18 months of initiation, 64.6% remained on dialysis, 4.5% had transitioned to peritoneal dialysis (PD), 2.0% had received a kidney transplant, and 25.4% had died (Figure 3.8a). As a percentage of all patients initiating HD in 2017, 43.5% remained on HD using an AV fistula, and 10.7% were receiving HD using an AV graft.
