Forearm Versus Upper Arm Location of Arteriovenous Access Used at Hemodialysis Initiation: Temporal Trends and Racial Disparities

Rationale & objective: Race and ethnicity differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated race and ethnicity differences in the use of an AVA in the forearm location at HD initiation.

Study design: Retrospective cohort study.

Setting & participants: Using records from DaVita Kidney Care linked to the US Renal Data System (USRDS), we evaluated patients aged≥16 years who initiated in-center HD with an AVA between 2006 and 2019.

Predictor: Race and ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other.

Outcome: Forearm versus upper arm AVA location.

Analytical approach: Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and race and ethnicity differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of race and ethnicity differences.

Results: Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease but less likely to have diabetes compared with the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race and ethnicity by calendar year interaction P=0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA.

Limitations: Findings may not apply to home HD.

Conclusions: Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research toward understanding the causes and consequences of these trends and disparities is warranted.