title: Vascular access for intensive maintenance hemodialysis: a systematic review for a Canadian Society of Nephrology clinical practice guideline.
abstract: BACKGROUND
  Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis.
  
  
  METHODS
  We conducted a systematic review to inform clinical practice guidelines for the provision of intensive hemodialysis.
  
  
  METHODS
  Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent [≥5 hemodialysis treatments per week] and/or long [>5.5 hours per hemodialysis treatment]).
  
  
  METHODS
  We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011).
  
  
  METHODS
  (1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users.
  
  
  RESULTS
  Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life.
  
  
  RESULTS
  We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices.
  
  
  CONCLUSIONS
  Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors.
  
  
  CONCLUSIONS
  This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.
authors.affiliation: Department of Clinical Epidemiology and Biostastistics, McMaster University, Hamilton, Ontario, Canada. ramustafa@gmail.com
authors.forename: Reem A
authors.initials: RA
authors.lastname: Mustafa
authors.forename: Deborah
authors.initials: D
authors.lastname: Zimmerman
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Rioux
authors.forename: Rita S
authors.initials: RS
authors.lastname: Suri
authors.forename: Azim
authors.initials: A
authors.lastname: Gangji
authors.forename: Andrew
authors.initials: A
authors.lastname: Steele
authors.forename: Jennifer
authors.initials: J
authors.lastname: MacRae
authors.forename: Robert P
authors.initials: RP
authors.lastname: Pauly
authors.forename: David N
authors.initials: DN
authors.lastname: Perkins
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Chan
authors.forename: Michael
authors.initials: M
authors.lastname: Copland
authors.forename: Paul
authors.initials: P
authors.lastname: Komenda
authors.forename: Philip A
authors.initials: PA
authors.lastname: McFarlane
authors.forename: Robert
authors.initials: R
authors.lastname: Lindsay
authors.forename: Andreas
authors.initials: A
authors.lastname: Pierratos
authors.forename: Gihad E
authors.initials: GE
authors.lastname: Nesrallah
mesh_terms: D002170:Canada; D002408:Catheters, Indwelling / Q000592:standards*; D006801:Humans; D009398:Nephrology / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*; D016032:Randomized Controlled Trials as Topic / Q000379:methods / Q000592:standards; D006435:Renal Dialysis / Q000379:methods / Q000592:standards*