Central venous catheters for chronic hemodialysis: Is “last choice” never the “right choice”?

Abstract

Since the publication of the first vascular access clinical practice guidelines in 1997, the global nephrology community has dedicated significant time and resources toward increasing the prevalence of arteriovenous fistulas and decreasing the prevalence of central venous catheters for hemodialysis. These efforts have been bolstered by observational studies showing an association between catheter use and increased patient morbidity and mortality. To date, however, no randomized comparisons of the outcomes of different forms of vascular access have been conducted. There is mounting evidence that much of the difference in patient outcomes may be explained by patient factors, rather than choice of vascular access.Some have called into question the appropriateness of fistula creation for certain patient populations, such as those with limited life expectancy and those at high risk of fistula-related complications. In this review, we explore the extent to which catheters and fistulas exhibit the characteristics of the "ideal" vascular access and highlight the significant knowledge gaps that exist in the current literature.Further studies, ideally randomized comparisons of different forms of vascular access, are required to better inform shared decision making.Twenty years ago, fistulas were first promoted as the vascular access of choice by the Kidney Disease Outcomes Quality Initiative.1 Since then, the nephrology community has worked to increase fistula prevalence and reduce the use of central venous catheters. These efforts have been supported by initiatives such as Fistula First, 2 clinical practice guidelines from around the world, [3][4][5][6] and in some jurisdictions, by financial incentives which reward dialysis centers with high fistula prevalence and penalize those with high catheter prevalence. 7 In 2007, a modification of the Fistula First Initiative to "Fistula First, Catheter Last" was proposed, re-emphasizing the perceived importance of minimizing catheter use. 8 However, critics of "Fistula First, Catheter Last" have expressed concern that all comparisons between access types have been observational, subject to high degrees of bias, 9,10 and unable to account for other patient factors which likely contribute to poor outcomes seen in patients treated with catheters. 11,12 Others have questioned the utility of fistula creation in elderly patients and in patients at high risk for fistula failure or complications, arguing that such patients may be better served by catheters. 13 Surveys of the nephrology community suggest that many clinicians feel that a catheter is often appropriate and that there is equipoise regarding the ideal form of vascular access in many situations. 14,15 In fact, enrollment recently began for a pilot randomized trial comparing outcomes in incident hemodialysis patients, over the age of 65, who start dialysis with a catheter. Patients will be randomized to creation of a fistula vs continued use of a catheter (clinicaltrials.gov NCT02675569). 16The ideal vascular access has...

Early cannulation grafts for haemodialysis: An updated systematic review

“…Although there is some evidence for EC of standard ePTFE grafts, these have not been recommended by the manufacturers. 28,29 The introduction of EC grafts has allowed a new and clear application of AVG to avoid or minimize the requirement of a CVC.…”

“…The perceived survival benefits from this type of access are largely disregarded due to selection and lead time bias. 27,28 Studies have shown primary patency advantages of AVG over AVFs for the first 2 years; however, there is an increased intervention rate and a higher risk of infection. Attempts to improve this have been introduced with newer generation grafts.…”

Barriers to optimal vascular access for hemodialysis

“…10,11,19 While in general, a CVC remains the least desirable access because of its increased morbidity, infection risk, and mortality, 3,[20][21][22][23] there are many patients for whom a CVC becomes the most necessary vascular access. 3,8,9 Obviously, patients without a permanent access or with an unusable AVF or AVG will require a CVC, but there are increasing circumstances in which a CVC may be preferable, such as after multiple failed AVF/ AVG creation attempts, interventional procedures, arterial steal syndrome, or based on selected patient characteristics to be described below. 8,9,[24][25][26] Other conditions causing disadvantages posed by the current vascular access options are listed in Table 2.…”

“…8,9,[24][25][26] Other conditions causing disadvantages posed by the current vascular access options are listed in Table 2. 3,8,9,11,27…”

“…3 KDOQI now espouses that "attainment of the 'right access, in the right patient, at the right time, for the right reasons' is a more patient-centered approach to care, where population measures, such as percentage with AVF created or used, or the percentage with hemodialysis CVC, may be unhelpful and counterproductive for patient-centered goals". 3 Attaining a goal of the "right access" has proved elusive mainly because, as depicted by the characteristics desirable for the optimal vascular access shown in Table 1, 3,8,9 the optimal vascular access does not currently exist. Thus, ESKD care providers attempting to offer the right access must weigh the barriers to achieving the most optimal vascular access to suit each of their HD patients individually.…”