The Case Against Chronic Venous Hemodialysis Access

Abstract

The provision of adequate hemodialysis is dependent on repeated and reliable access to the central circulation. This access to the circulation is best provided by primary arteriovenous fistulas (AVF) and to a lesser extent by AV grafts (AVG). AVF have the lowest rates of infection and thrombosis and are therefore the access of choice whenever vascular anatomy allows (1,2). On the other hand, establishing primary AVF in an ever-aging end-stage renal disease (ESRD) patient population with a high prevalence of diabetes and vascular disease has proved a daunting task, at least in the United States. Late referrals to nephrologists make establishment of AVF more difficult. Therefore, our reliance on less desirable modes of vascular access such as synthetic (PTFE) grafts and tunneled, cuffed catheters (CVC) has increased. In fact, up to 60% of new patients and 30% of prevalent patients are using a catheter for dialysis access (3). These latter two accesses are more prone to both thrombosis and infection. Venous access in particular has emerged as a substantial cause of hemodialysis morbidity and mortality. Two articles in this issue of JASN deal with these dilemmas (4,5).Catheter-related bacteremia remains the most common and potentially serious complication of long-term venous access (6 -8). Initial reports of tunneled, cuffed catheters reported low rates of bacteremia, but these were maintained in patients for a relatively short duration. In our original description, for example, median catheter use was only 8 wk, ranging from 3 wk to 5.4 mo (9). In this early report, only one episode of bacteremia occurred in 80 dual lumen catheters. Two more recent studies each showed bacteremia to occur about once every 200 to 250 catheter-days. In the first study, Marr et al. (10) followed 102 patients with CVC for total of 16,081 catheter-days. Bacteremia occurred in this study at a rate of 3.9/1000 catheter-days. Similar to Marr's data, Saad described a mean bacteremia rate of 5.5/1000 catheter-days (11).In our experience, metastatic complications, such as vertebral osteomyelitis, septic arthritis, and endocarditis, have only rarely been seen among our patients in the absence of indwelling catheters. Kovalik et al. (12) demonstrated a significant increase in vertebral osteomyelitis and epidural abscess in patients with dialysis catheters versus AVG. Likewise, Robinson et al. (13) showed that endocarditis occurred at a much higher rate in patients with catheters and was relatively rare in patients using synthetic grafts or AVF. Hence, dialysis with a catheter not only increases the rate of bacteremia but also appears to increase the rate of complications from an individual episode of bacteremia.Furthermore, frequent problems maintaining catheter blood flow in CVC reduce dialysis efficiency and delivered Kt/V. Repeated studies have shown consistently lower delivered dialysis dose with catheters when compared with either grafts or fistulas. For instance, Sehgal et al. (14) demonstrated Kt/V of 1.37 and 1.31 with AVG and AVF, re...

Outcomes of Upper Arm Arteriovenous Fistulas for Maintenance Hemodialysis Access

“…Synthetic arteriovenous grafts have the advantage of needing less time to mature than do AVFs. However, because of the inferior patency and increased complication rates associated with grafts, [6][7][8][9] the DOQI has recommended that surgeons increase the proportion of fistulas being placed in patients with ESRD. 2 This clear need for a Abbreviation: AVF, arteriovenous fistula.…”

“…6 These grafts have been shown in multiple studies to have lower patency and higher complication rates than do native radiocephalic fistulas. [6][7][8][9] Consequently, the National Kidney Foundation, New York, NY, in the Dialysis Outcomes Quality Initiative (DOQI) recently established new guidelines regarding hemodialysis access for maintenance hemodialysis and recommended that at least 50% of new hemodialysis access procedures involve the creation of a native AVF rather than placement of a prosthetic graft. 2 To meet this challenge, surgeons must be able to create additional sites for AVFs.…”

How arteriovenous grafts could help to optimize vascular access management

“…Catheter‐related bacteremia occurred with an incidence of 0.45/1000 catheter days for gentamicin and citrate lock and 1.68/1000 catheter days for heparin lock . Catheters are also prone to the limitation of blood flow due to thrombosis or fibrin sheath formation . The third significant complication is central vein stenosis .…”

“…14 Catheters are also prone to the limitation of blood flow due to thrombosis or fibrin sheath formation. 47 The third significant complication is central vein stenosis. 48 The shift in strategy toward catheter sparing or avoidance has brought back the advantages of an AVG to the forefront.…”

Epidemiology of Vascular Access for Hemodialysis and Related Practice Patterns

“…The greatest morbidity and mortality are associated with the use of dialysis catheters, the major risks being infection and thrombosis with resultant bacteremia, sepsis, potential for metastatic infections and endocarditis [31]. In an important study based on the US Renal Data System Dialysis Morbidity and Mortality Wave 1 Study, Dhingra et al [32] found significantly increased relative risk of mortality with the use of central venous catheters compared to AVG or AVF over a 2-year follow-up period.…”