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Tunneled Catheter Avoidance- Seven Simple Strategies Anil Agarwal, MD, FASN, FNKF, FACP Professor of Clinical Medicine Director, Interventional Nephrology Chief, Section of Nephrology at University Hospital East Wexner Medical Center at The Ohio State University September 7, 2016

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Objectives  Discuss catheters as a necessary evil  Factors promoting catheter utilization  Suggest strategies to avoid catheters 4

More Than 80% of Patients Start HD with a Catheter in US  5 fold greater mortality in first 90 days on HD  Not a failure of technology or biology  Dismal failure of communication and logistics!!  Process of Care USRDS 2013 5

Any Prolongation in Catheter Duration is Bad! 15% infection rate Lee et al. AJKD

Catheters Kill! 5 fold increase in mortality HD/PD CVC Peak mortality rate with a CVC in 1 st 90d = 70 per 100 patient years Peak mortality rate with an AVF in 1 st 90d = 15 per 100 patient years Perl et al. JASN 2011

Fate of Catheter Through 180 Days

Bottom Line (Survival and Cost)  Patients with a catheter (TDC) die quicker and cost more!  Patients with an AVF or AVC live longer and cost less!

Strategy #1 to Avoid Catheters – Early Referral  30-40% are referred late to the nephrologist <4 months before starting HD 90% 62%

Strategy #2 – Educate the Patient  Avoid patient refusal through education Feb 2010 Results

Strategy #3 – Preserve the Veins  Peripheral and central veins should be saved!  Avoid IVs, PICC lines, CVCs

Strategy #4 – For Failing AVF/AVG – Create a Secondary AV Fistula Slayden et al. Semin Dial. 2008 Sep-Oct;21(5):474

Strategy #5 – Early Cannulation AV Grafts ePTFE Acuseal 40% Acuseals cannulated within 72 hrs

For Patient Needing Urgent Dialysis ( 1 – 2 Weeks) Patient needs urgent dialysis X (not today but in 1-2 wks) 3-4 months of Rapid Early Use WAIT a TDC with start PD AV Graft multiple AVF interventions 3-4 wks 3-4 wks 6-12 weeks Standard PD Standard PTFE AVF

Strategy #6 – Don’t Forget the “Good Catheter”

Strategy #6 – For a Patient Needing Immediate Dialysis Patient needs immediate dialysis (pulm edema, BUN = 150, Creat. = 20) Temp. catheter, HD started X Early Urgent Use start PD 3-4 months of Grafts a TDC with multiple AVF Secondary AVF interventions

Strategy #7 – The Gift of Life!

The Ultimate Strategy – Develop A Catheter Last Culture  Use a Fistula First + catheter Last  Catheter out , and  Catheter never in paradigm

Back to the Future ? Place Scribner Shunt- then create a secondary AVF or AVG

Thanks to Prabir Roy-Chaudhury, MD for making available many of his slides

Any Questions ?

Objectives  Discuss catheters as a necessary evil  Factors promoting catheter utilization  Suggest strategies to avoid catheters 23

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