{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T17:43:15Z","timestamp":1790790195071,"version":"4.1.0"},"reference-count":32,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["CJASN"],"published-print":{"date-parts":[[2017,6]]},"abstract":"\n Background and objectives<\/jats:title>\n People receiving hemodialysis to treat kidney failure need a vascular access (a fistula, a graft, or a central venous catheter) to connect to the blood purification machine. Higher rates of access complications are considered the mechanism responsible for the excess mortality observed among catheter or graft users versus fistula users. We tested this hypothesis using mediation analysis.<\/jats:p>\n <\/jats:sec>\n \n Design, setting, participants, & measurements<\/jats:title>\n \n We studied incident patients who started hemodialysis therapy from North America, Europe, and Australasia (the Dialysis Outcomes and Practice Patterns Study; 1996\u20132011). We evaluated the association between access type and time to noninfectious (\n e.g.<\/jats:italic>\n , thrombosis) and infectious complications of the access (mediator model) and the relationship between access type and time-dependent access complications with 6-month mortality from the creation of the first permanent access (outcome model). In mediation analysis, we formally tested whether access complications explain the association between access type and mortality.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Of the 6119 adults that we studied (mean age =64 [SD=15] years old; 58% men; 47% patients with diabetes), 50% had a permanent catheter for vascular access, 37% had a fistula, and 13% had a graft. During the 6-month study follow-up, 2084 participants (34%) developed a noninfectious complication of the access, 542 (8.9%) developed an infectious complication, and 526 (8.6%) died. Access type predicted the occurrence of access complications; both access type and complications predicted mortality. The associations between access type and mortality were nearly identical in models excluding and including access complications (hazard ratio, 2.00; 95% confidence interval, 1.55 to 2.58 versus hazard ratio, 2.01; 95% confidence interval, 1.56 to 2.59 for catheter versus fistula, respectively). In mediation analysis, higher mortality with catheters or grafts versus fistulas was not the result of increased rates of access complications.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Hemodialysis access complications do not seem to explain the association between access type and mortality. Clinical trials are needed to clarify whether these associations are causal or reflect confounding by underlying disease severity.<\/jats:p>\n <\/jats:sec>","DOI":"10.2215\/cjn.12181116","type":"journal-article","created":{"date-parts":[[2017,5,18]],"date-time":"2017-05-18T20:50:20Z","timestamp":1495140620000},"page":"955-964","source":"Crossref","is-referenced-by-count":130,"title":["Examining the Association between Hemodialysis Access Type and Mortality: The Role of Access Complications"],"prefix":"10.2215","volume":"12","author":[{"given":"Pietro","family":"Ravani","sequence":"first","affiliation":[{"name":"Medicine and"},{"name":"Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Quinn","sequence":"additional","affiliation":[{"name":"Medicine and"},{"name":"Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Oliver","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Toronto, Toronto, Ontario, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruce","family":"Robinson","sequence":"additional","affiliation":[{"name":"Arbor Research Collaborative for Health, Ann Arbor, Michigan;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronald","family":"Pisoni","sequence":"additional","affiliation":[{"name":"Arbor Research Collaborative for Health, Ann Arbor, Michigan;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neesh","family":"Pannu","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"MacRae","sequence":"additional","affiliation":[{"name":"Medicine and"},{"name":"Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Braden","family":"Manns","sequence":"additional","affiliation":[{"name":"Medicine and"},{"name":"Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brenda","family":"Hemmelgarn","sequence":"additional","affiliation":[{"name":"Medicine and"},{"name":"Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"James","sequence":"additional","affiliation":[{"name":"Medicine and"},{"name":"Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcello","family":"Tonelli","sequence":"additional","affiliation":[{"name":"Medicine and"},{"name":"Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brenda","family":"Gillespie","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2017,5,18]]},"reference":[{"key":"B1-20230813","doi-asserted-by":"crossref","first-page":"1975","DOI":"10.1016\/S0140-6736(14)61601-9","article-title":"Worldwide access to treatment for end-stage kidney disease: A systematic review.","volume":"385","author":"Liyanage","year":"2015","journal-title":"Lancet"},{"key":"B2-20230813","doi-asserted-by":"crossref","first-page":"2621","DOI":"10.1681\/ASN.2014101017","article-title":"Maintenance dialysis throughout the world in years 1990 and 2010.","volume":"26","author":"Thomas","year":"2015","journal-title":"J Am Soc Nephrol"},{"key":"B4-20230813","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1681\/ASN.2004050355","article-title":"Establishment and maintenance of vascular access in incident hemodialysis patients: A prospective cost analysis.","volume":"16","author":"Manns","year":"2005","journal-title":"J Am Soc Nephrol"},{"key":"B5-20230813","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1681\/ASN.2010121219","article-title":"Medicare reimbursement policies and hemodialysis vascular access outcomes: A need for change.","volume":"22","author":"Allon","year":"2011","journal-title":"J Am Soc Nephrol"},{"key":"B7-20230813","doi-asserted-by":"crossref","first-page":"1629","DOI":"10.1681\/ASN.2008020172","article-title":"Resolved: Fistulas are preferred to grafts as initial vascular access for dialysis. 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