Fistula First or Catheter Last?

The management of chronic kidney disease is directly related to the patients’ ability to receive high quality dialysis. The creation of a reliable access is imperative to achieve this goal. Access options for these patients include arteriovenous fistula (AVF), arteriovenous graft (AVG), peritoneal dialysis (PD) catheters and central venous catheters (CVC). While each type of access has risks and benefits evidence has shown that a high quality AVF is the optimal access in dialysis patients. In order to standardize access creation many guidelines have been developed focusing on a “fistula first” mentality. These efforts have been very successful with a fistula rate of over 60% as of 2011. Unfortunately, the push for fistula creation has had the undesired consequence of increasing CVC catheter use with the associated morbidity and mortality, with catheter rates as high as 25% in some studies. The more recent concepts of “Fistula First, Catheter Last” and the latest updates to the KDOQI guidelines focusing on the patients’ life-long access plan have been put in place to reduce catheter use and limit the associated complications. These new guidelines aim to increased AVF creation in appropriate patients but also decrease long term CVC rates to <10%. Most importantly these guidelines recognize that all patients access plan needs to be individualized. While catheters are associated with many known complications such as increased infection risk, they also have unique benefits including ease of placement, patient comfort and ability to be used immediately. In some patients, catheters may be the only option for dialysis will always have a role in the management of dialysis patients.