Acute and Chronic Catheter in Hemodialysis

Abstract

Reliable and sustained access to the circulation is mandatory for the provision of long-term hemodialysis which is critical to the survival of patients with end-stage renal disease (ESRD). An ideal vascular access provides adequate blood flow to meet the hemodialysis prescription, with minimal complications due to infection or thrombosis. The natural arteriovenous fistula (AVFs) comes closest to meeting these criteria while arteriovenous grafts (AVGs) and central venous catheters (CVCs) present other vascular access options. In the United States, promoting a major shift in using fistula as first-choice vascular access has been strongly recommended by the 2001 Kidney Disease Outcome Quality Initiative (K/DOQI) vascular access guideline (NKF-DOQI 2001) and the “Fistula First” national initiative (Tonnessen et al 2005). Ideally, every patient would initiate dialysis with a mature fistula suitable for cannulation. In real clinical setting, this is not true due to combination of the following factors including (i) lacking nephrology follow-up at the time of ESRD, (ii) late nephrology referral, (iii) poor or no planning of fistula placement, (iv) inadequate fistula maturation and (v) poor vascular preparation due to prior venous cannulation. In current practice, 20-50% of attempted AVFs fail to mature adequately. Despite a recent increase in the number of prevalent patients dialyzing with an AVF (47%) in the US following the fistula-first initiative, 28% of prevalent patients remain dependent on an AVG and 25% on a CVC. In Canada, recent data demonstrate that 50% of patients use an AVF, while 39% and 11% depends on a CVC or AVG, respectively (James et al 2009). Sadly, hemodialysis CVCs are increasingly being introduced in patients requiring emergency or chronic renal replacement therapy. Table 1 outlines the advantages and disadvantages of CVCs. The percentages of patients undergoing dialysis with vascular catheters are increasing in Europe, ranging from 15% (Germany) to 50% (United Kingdom) of all hemodialysis patients. In the United States, up to 60% of patients start hemodialysis with CVCs (Pisoni et al 2002). Over the last decade, the number of patients using CVCs for hemodialysis doubled (Rayner et al 2004). According to the Dialysis Outcomes and Practice Patterns Study, 18% of patients with end-stage renal failure in the United States and 24% of those in Great Britain have been dialysed with such catheters (Quarello et al 2006). Table 2 summarizes the indication for using CVCs. Recent studies indicate that CVCs are used in 2025% of incident ( 6 months) (Rayner et al 2004a, Moist et all 2007). The use of CVCs has been complicated by higher rates of thrombosis, dysfunction,