Who Is Truly Catheter Dependent?

A large percentage of dialysis patients start dialysis using a tunneled dialysis catheter (TDC). These catheters are associated with a high risk of infection, central venous stenosis and occlusion, and mortality. In the modern era, a surprising amount of inflow and virtually all outflow problems can be treated, allowing “permanent” access creation. That said, a significant portion of the hemodialysis population suffers from significant comorbidities that complicate dialysis access planning and obviate the “theoretical” fix for such problems. In general, the greatest barriers to creation of long-term hemodialysis can be classified into physiologic, anatomic, and global factors. Physiological factors are those that limit patients’ tolerance to the procedure itself or the resulting high blood flow, anatomical factors are those that limit the available sites an access can be placed, and global conditions, divided into medical conditions that significantly limit life expectancy or psychosocial reasons for not pursuing longer-term access options, are those that are due to overall patient factors rather than anatomy or physiology. Each should be assessed thoroughly when this issue arises.