Central venous catheter (CVC) use at hemodialysis (HD) initiation remains high, despite reports of CVC-associated morbidity and mortality, and efforts at early arteriovenous fistula placement. In order to determine predictors of CVC use at the start of HD, data from the end-stage renal disease (ESRD) Clinical Performance Measures (CPM) Project was linked to the Centers for Medicare & Medicaid Services Medical Evidence (2728) Form. Of the 4071 incident hemodialysis patients in study years 1999-2003, 71.6% used a CVC at dialysis initiation. After controlling for demographic and co-morbid variables, patients with a CVC were 24% more likely to be female (p = 0.006), and 38% more likely to have ischemic heart disease (p = 0.002), while those with obesity (BMI > or = 30) were 24% less likely to start dialysis with a CVC (p = 0.006). Pre-ESRD hypoalbuminemia (< 3.5 g/dl) was associated with a twofold higher risk of CVC use (p = < 0.001), while patients with pre-ESRD anemia (hgb < 11 g/dl) were 29% more likely to use a CVC at dialysis initiation (p = 0.006) compared to those with hemoglobin > or = 11 g/dl. Patients receiving predialysis erythropoietin had a 41% lower odds of CVC use at dialysis initiation (p = < 0.001). Finally, dialysis year was predictive of CVC use; in 2002, 76% of patients initiated dialysis with a CVC compared with 66% in 1998 (p < 0.001). Overall, female gender, ischemic heart disease, lack of obesity, factors suggesting poor pre-ESRD care, and successive year of dialysis initiation were predictive of CVC use at hemodialysis initiation.