Incidence and Risk Factors of Sepsis in Hemodialysis Patients in the United States

Satinderjit Locham, Isaac Naazie, Joseph Canner, Jeffrey Siracuse, Omar Al-Nouri, Mahmoud Malas
Journal of Vascular Surgery 2020 July 21

BACKGROUND: Sepsis is one the most serious and life-threatening complication in patients with chronic hemodialysis access (HD). Arteriovenous fistula (AVF) use is associated with lower risk of infection. However, several prior studies identified significantly higher number of patients initiating hemodialysis using catheter (HC) or graft (AVG). The aim of this study is to use a large national Renal Database to report the incidence and risk factors of Sepsis in patients with end stage renal disease (ESRD) initiating hemodialysis access using AVF, AVG or HC in the United States.

METHODS: All ESRD patients initiating HD access (AVF, AVG, HC) between 1/1/2006 and 12/31/2014 in United States Renal Data System (USRDS) were included. ICD-9-CM diagnosis code (038x, 790.7) was used to identify patients that developed first onset of sepsis during follow-up. Standard univariate (Students t-test, Chi-square, Kaplan-Meier) and multivariable (Logistic/Cox-regression) analysis was performed as appropriate.

RESULTS: A total of 870,571 patients were identified. Of which, 29.8% (N=259,686) developed Sepsis. HC (31.2%) and AVG (30.6%) were associated with higher number of septic cases compared to AVF (22.9%) (P<.001). The incident rate of sepsis was 12.66 episodes per 100 person-years. Of which, it was the highest among HC vs. AVG vs. AVF (13.86 vs. 11.49 vs. 8.03 per 100 person-years). Patients with sepsis were slightly older (mean age (S.D.): 65.09(14.49) vs. 63.24(15.17)) and had higher number of comorbidities including obesity (40.7% vs. 37.7%), congestive heart failure (36.6% vs. 30.8%), peripheral arterial disease (15.6% vs. 12.4%), and diabetes (59.6% vs. 53.5%) (All P<.001). After adjusting for potential confounders, compared to AVF, patients with AVG (HR(95% CI): 1.35(1.31-1.40)) and HC (HR(95% CI): 1.80(1.77-1.84)) were more likely to develop sepsis at 3 years (Both P<.001). Compared to patients with no sepsis, sepsis was associated with three folds increase odds of mortality (OR(95%CI): 3.16(3.11-3.21), p<.001). Additionally, in patients that developed sepsis, AVF use was associated with significantly lower mortality compared to AVG and HC (73.7% vs. 78.7% and 78.0%, P<.001). After adjusting for significant covariates, compared to AVF, mortality at 1 year following sepsis was 21% higher in AVG (HR(95% CI): 1.21(1.15-1.28), p<.001) and nearly doubled in HC (HR(95% CI): 1.94(1.88-2.00), P<.001).

CONCLUSION: Sepsis risk in HD patients is clearly related to access type and is associated with dramatic increase in mortality. Initiating HD access with AVF to meet the National Kidney Foundation Kidney Disease Outcomes Quality (NFK-KDOQI) recommendations should be implemented to reduce the incidence of sepsis and improve survival in ESRD patients.

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