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      Strategies to Minimize Tunneled Hemodialysis Catheter Use


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          While the use of arteriovenous grafts has recently declined, there has been an astronomical increase in hemodialysis patients dialyzing with tunneled dialysis catheters (TDCs). Recent data have indicated that over 70% of the patients with end-stage renal disease initiate dialysis with a catheter. Additionally, up to 27% of the end-stage renal disease patients in the US are using TDCs as their permanent access, with placement rates having doubled since 1996. Although most modern catheters claim to provide adequate blood flow for dialysis, they are associated with the highest incidence of complications, morbidity and mortality when compared with other types of vascular access. It is for these reasons that the National Kidney Foundation Dialysis Outcomes Quality Initiative guideline 30 as well as the Fistula First Change Concept 7 emphasize limiting the use of catheters and fostering the creation of arteriovenous fistulae. Early referral has clearly been shown to minimize the use of TDCs and maximize fistulae. This report focuses on the role of additional measures that minimize TDC use, such as dialysis modality presentation and peritoneal dialysis, vascular access education, preoperative vascular mapping and salvage of early failure and thrombosed fistulae.

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          Most cited references24

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          Type of vascular access and mortality in U.S. hemodialysis patients.

          Vascular access (VA) complications account for 16 to 25% of hospital admissions. This study tested the hypothesis that the type of VA in use is correlated with overall mortality and cause-specific mortality. Data were analyzed from the U.S. Renal Data System Dialysis Morbidity and Mortality Study Wave 1, a random sample of 5507 patients, prevalent on hemodialysis as of December 31, 1993. The relative mortality risk during a two-year observation was analyzed by Cox-regression methods with adjustments for demographic and comorbid conditions. Using similar methods, cause-specific analyses also were performed for death caused by infection and cardiac causes. In diabetic mellitus (DM) patients with end-stage renal disease, the associated relative mortality risk was higher for those with arteriovenous graft (AVG; RR = 1.41, P < 0.003) and central venous catheter (CVC; RR = 1.54, P < 0.002) as compared with arteriovenous fistula (AVF). In non-DM patients, those with CVC had a higher associated mortality (RR = 1.70, P < 0.001), as did to a lesser degree those with AVG (RR = 1.08, P = 0.35) when compared with AVF. Cause-specific analyses found higher infection-related deaths for CVC (RR = 2.30, P < 0.06) and AVG (RR = 2.47, P < 0.02) compared with AVF in DM; in non-DM, risk was higher also for CVC (RR = 1.83, P < 0.04) and AVG (RR = 1.27, P < 0.33). In contrast to our hypothesis that AV shunting increases cardiac risk, deaths caused by cardiac causes were higher in CVC than AVF for both DM (RR = 1.47, P < 0.05) and non-DM (RR = 1.34, P < 0.05) patients. This case-mix adjusted analysis suggests that CVC and AVG are correlated with increased mortality risk when compared with AVF, both overall and by major causes of death.
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            Vascular access and increased risk of death among hemodialysis patients.

            Hemodialysis with a venous catheter increases the risk of infection. The extent to which venous catheters are associated with an increased risk of death among hemodialysis patients has not been extensively studied. We conducted a retrospective cohort study of 7497 prevalent hemodialysis patients to assess the association between dialysis with a venous catheter and risk of death due to all causes and to infection. A tunneled cuffed catheter was used for access in 12% of the patients and non-cuffed, not tunneled catheter in 2%. Younger age (P = 0.0005), black race (P = 0.0022), female gender (P = 0.0004), short duration since starting dialysis (P = 0.0003) and impaired functional status (P = 0.0001) were independently associated with increased use of catheter access. The proportion of patients who died was higher among those who were dialyzed with a non-cuffed (16.8%) or cuffed (15.2%) catheter compared to those dialyzed with either a graft (9.1%) or a fistula (7.3%; P < 0.001). The proportion of deaths due to infection was higher among patients dialyzed with a catheter (3.4%) compared to those dialyzed with either a graft (1.2%) or a fistula (0.8%; P < 0.001). The adjusted odds ratio (95% CI) for all-cause and infection-related death among patients dialyzed with a catheter was 1.4 (1.1, 1.9) and 3.0 (1.4, 6.6), respectively, compared to those with an arteriovenous (AV) fistula. Venous catheters are associated with an increased risk of all-cause and infection-related mortality among hemodialysis patients.
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              Hemodialysis arteriovenous fistula maturity: US evaluation.

              To compare various objective ultrasonographic (US) criteria for native arteriovenous fistula (AVF) maturation with subsequent fistula outcomes and clinical evaluation by experienced dialysis nurses. US fistula evaluation results were analyzed retrospectively in 69 patients within 4 months after AVF placement; adequacy for dialysis was known in 54. Measurements included minimum venous diameter and blood flow rate. Experienced dialysis nurses examined 30 fistulas clinically. Predictors of fistula adequacy were analyzed with univariate and multivariate logistic regression. Mean fistula diameters and blood flow rates were compared by using analysis of variance or unpaired Student t tests. Fistula adequacy for dialysis doubled if the minimum venous diameter was 0.4 cm or greater (89% [24 of 27]) versus less than 0.4 cm (44% [12 of 27]; P <.001). Fistula adequacy for dialysis was nearly doubled if flow volume was 500 mL/min or greater (84% [26 of 31]) versus less than 500 mL/min (43% [nine of 21]; P =.002). Combining venous diameter and flow volume increased fistula adequacy predictive value: minimum venous diameter of 0.4 cm or greater and flow volume of 500 mL/min or greater (95% [19 of 20]) versus neither criterion met (33% [five of 15]; P =.002). Women were less likely to have an adequate fistula diameter of 0.4 cm or greater: 40% (12 of 30) of women versus 69% (27 of 39; P =.015) of men. No significant differences in blood flow or minimum venous diameter were found during 2-4 postoperative months. Experienced dialysis nurses' accuracy in predicting eventual fistula maturity was 80% (24 of 30). US measurements of AVF at 2-4 months in patients undergoing hemodialysis are highly predictive of fistula maturation and adequacy for dialysis.

                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                December 2005
                23 December 2005
                : 24
                : 1
                : 90-94
                Section of Interventional Nephrology, Division of Nephrology, University of Miami Miller School of Medicine, Miami, Fla., USA
                89443 Blood Purif 2006;24:90–94
                © 2006 S. Karger AG, Basel

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                Page count
                References: 41, Pages: 5
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/89443
                Self URI (text/html): https://www.karger.com/Article/FullText/89443
                Self URI (journal page): https://www.karger.com/SubjectArea/Nephrology

                Cardiovascular Medicine,Nephrology
                Early fistula failure,Peritoneal dialysis,Interventional nephrology,Fistula thrombosis


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