Guidelines for hemodialysis access for acute renal failure patients may need revision, data suggest.
WASHINGTON, D.C.—Primary placement of tunneled dialysis catheters (TDCs) in patients with acute renal failure (ARF) requiring hemodialysis may be better than using nontunneled dialysis catheters (NTDCs), according to researchers.
The finding suggests that guidelines from the National Kidney Foundation’s Kidney Disease Out-comes Quality Initiative (K/DOQI) for NTDCs in this patient population may require revision.
“The problem with the guidelines is that you can’t predict who is going to need a catheter for longer than a week,” said senior investigator Scott Trerotola, MD, chief of interventional radiology and a professor of radiology who presented findings here at the Society for Interventional Radiology annual meeting. “So the standard is to put a nontunneled dialysis catheter and then put another one in later if they need it. But that subjects patients to multiple procedures.”
NTDCs are widely used as initial hemodialysis access in new onset renal failure primarily because of the K/DOQI guidelines. The K/DOQI recommendations for hemodialysis access in ARF are that NTDCs should be used for dialysis duration of less than one week because of the increased risk of infection with longer use compared with TDCs. It is often difficult, however, to predict when a patient will recover renal function.
At their institution, by mutual consent of the dialysis access team, a TDC was placed in all ARF patients referred to interventional radiology and who had no contraindications to TDCs (e.g., uncorrectable coagulopathy, thrombocytopenia, bacteremia).
The researchers studied 76 patients who received primary TDCs for ARF and whose indication for removal was recovery of renal function. The patients had a mean age of 56 years and 42% were female. The researchers analyzed TDC dwell times, and also looked at the cause of renal failure, various renal function parameters, and demographics to deter-mine predictors of recovery and/or extended duration of use.
The mean TDC dwell time in patients who eventually recovered from ARF was 34 days; only 15 of the 76 patients (20%) recovered renal function within one week. At the time of TDC placement, the mean serum creatinine level was 6.2 mg/dL, 24-hour urine volume was 781 mL, and the duration of oliguria was 0.8 days. The patients who recovered renal function in less than one week were similar to those who needed more than one week to recover renal function.
Overall, the mean TDC dwell time for patients recovering renal function was four weeks more than the maximum K/DOQI-recommended NTDC dwell time of one week. A total of 80% of patients did not recover by one week. The researchers were unable to identify any predictors of renal function recovery in less than one week. Neither the etiologies of renal failure nor the active comorbidities in patients who recovered in less than one week demonstrated a pattern discernible from those who recovered after more than one week. No gender differences were observed.
“Since we couldn’t find any predictors of who was going to recover, we think that tunneled catheters should be placed right from the start in acute renal failure, unless there are contraindications,” said lead investigator Lee Coryell, a fourth-year medical student at the University of Pennsylvania. “We also found that in 80% of the patients you can prevent having a second procedure with this approach.”
Coryell, who presented the findings at the meeting, said there are cost issues involved with TDCs as first catheters, but the study was not designed to determine whether the increased cost of placing a TDC would be outweighed by the decrease in cost by avoiding NTDC infections and multiple procedures.
“The K/DOQI guidelines should possibly be revised in light of these new data,” Dr. Trerotola said. “I think we would be very likely to lower morbidity and possibly mortality because we are avoiding non-tunneled catheters and repeated use of non-tunneled catheters and their associated high risks for infections.”