title: Overutilization of central venous catheters in incident hemodialysis patients: reasons and potential resolution strategies.
abstract: Even after adjusting for comorbidities, the outcomes in hemodialysis (HD) patients using a central venous catheter (CVC) as dialysis access are worse than in those with a permanent vascular access. In spite of this, nationwide data suggest that only about 25% of incident HD patients initiate dialysis with an arteriovenous fistula. We conducted a retrospective study to identify reasons and resolution strategies for CVC use in patients who initiated HD at an academic medical center with a well-established chronic kidney disease (CKD) clinic and a dedicated vascular surgeon. Estimated glomerular filtration rate (eGFR) loss over time to record progression of patients to HD was also examined. The charts of 170 consecutive patients were reviewed. Ninety-two percent were found to initiate HD using a CVC. Three factors explained 93% of all CVC in our cohort: absence of adequate predialysis care (45%), acute illness with failure to recover from an episode of acute renal failure (31%), and patient's failure to adhere to scheduled clinic or surgical appointments (17%). In addition, analyses of eGFR suggest that the velocity of GFR loss rather than a defined degree of renal function might be a better trigger for vascular access referral. We conclude that early referral, a close follow up of CKD patients who initiate dialysis due to acute illness, and patient education may have a positive impact to counteract overutilization of CVCs for dialysis. The rate in eGFR decline might also be used to calculate the referral time adequate for fistula creation.
authors.affiliation: Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. olenz@med.miami.edu
authors.forename: Oliver
authors.initials: O
authors.lastname: Lenz
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Sadhu
authors.forename: Alessia
authors.initials: A
authors.lastname: Fornoni
authors.forename: Arif
authors.initials: A
authors.lastname: Asif
mesh_terms: D058186:Acute Kidney Injury / Q000150:complications / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data; D015415:Biomarkers / Q000097:blood; D002405:Catheterization, Central Venous / Q000706:statistics & numerical data*; D003404:Creatinine / Q000097:blood; D003430:Cross-Sectional Studies; D018450:Disease Progression; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D012017:Referral and Consultation; D006435:Renal Dialysis / Q000295:instrumentation; D012107:Research Design; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures
chemical_list: D015415:Biomarkers; D003404:Creatinine