Abstract
BackgroundAcute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high morbidity, mortality and resource utilization. The type of vascular access placed for AKI-RRT is an important decision, for which there is a lack of evidence-based guidelines.MethodsWe conducted a prospective cohort study over a 16-month period with 154 patients initiated on AKI-RRT via either a non-tunneled dialysis catheter (NTDC) or a tunneled dialysis catheter (TDC) at an academic hospital. We compared differences in renal replacement delivery and mechanical and infectious outcomes between NTDCs and TDCs.ResultsPatients who received TDCs had significantly better RRT delivery, both with continuous venovenous hemofiltration (CVVH) and intermittent hemodialysis (IHD), compared to patients who received NTDCs; these findings were confirmed after multivariable adjustment for AKI-specific disease severity score, history of chronic kidney disease, renal consult team, and AKI cause. In CVVH and IHD, the median venous and arterial blood flow pressures were significantly higher with TDCs compared to NTDCs (p < 0.001). Additionally for CVVH, the median number of interruptions per catheter was higher with NTDCs compared to TDCs (Rate Ratio (RR) 2.7; p < 0.001), and for IHD, a higher median blood flow was seen with TDCs (p < 0.001). There were a significantly higher number of mechanical complications with NTDCs (RR 13.6 p = 0.001). No significant difference was observed between TDCs and NTDCs for positive blood cultures per catheter.ConclusionsCompared to NTDCs, TDCs for patients with AKI-RRT had improved RRT delivery and fewer mechanical complications. Initial TDC placement for AKI-RRT should be considered when not clinically contraindicated given the potential for improved RRT delivery and outcomes.
Highlights
Acute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high morbidity, mortality and resource utilization
Patients who received only non-tunneled dialysis catheters (NTDC) were more often treated with continuous venovenous hemofiltration (CVVH) and in the Intensive care unit (ICU) than those who received tunneled dialysis catheters (TDC) or both types of catheters
Patients who received only TDCs were more often treated with intermittent hemodialysis (IHD) and outside of the ICU than those who received NTDCs or both
Summary
Acute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high morbidity, mortality and resource utilization. AKI is life threatening and requires the initiation of renal replacement therapy (RRT), most commonly by intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). Unlike RRT for end stage renal disease (ESRD), RRT for AKI is most commonly performed using temporary non-tunneled dialysis catheters (NTDC) placed at the bedside. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest using NTDCs rather than TDCs for vascular access in AKI (level of evidence, 2D) primarily for logistical reasons – namely, ease of insertion and timeliness [4]. TDCs are recommended to replace NTDCs for more prolonged vascular access in severe AKI that requires ongoing RRT for greater than 1 week [12]
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