Original Investigation
Dialysis
Vascular Access for Intensive Maintenance Hemodialysis: A Systematic Review for a Canadian Society of Nephrology Clinical Practice Guideline

https://doi.org/10.1053/j.ajkd.2013.03.028Get rights and content

Background

Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis.

Study Design

We conducted a systematic review to inform clinical practice guidelines for the provision of intensive hemodialysis.

Setting & Population

Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent [≥5 hemodialysis treatments per week] and/or long [>5.5 hours per hemodialysis treatment]).

Selection Criteria for Studies

We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011).

Interventions

(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.

Outcomes

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.

Limitations

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.

Section snippets

Protocol and Registration

Our review adhered to prespecified protocols registered with the PROSPERO International Prospective Register of Systematic Reviews (registration numbers: CRD42012001966 and CRD42012001967).

Types of Studies

We included clinical trials, cohort studies, case series, and case reports. We excluded opinion pieces, editorials, narrative reviews, and other publication types that did not include original data.

Types of Participants

We included studies describing adult (aged >18 years at the initiation of dialysis therapy) patients receiving

Study Selection

Study selection details and reasons for exclusion are presented in Fig 1, with further details in Table S1. We screened 3,127 titles and abstracts and 951 full-text articles and identified a total of 36 relevant full-text citations in the first-stage screen, as well as 4 systematic reviews that were hand searched for additional references. The second-stage (grey literature, bibliographic, and targeted PubMed) search yielded 39 additional studies. A total of 40 studies were excluded, leaving 23,

Discussion

To date, practices for intensive hemodialysis provision have evolved primarily from those used for patients receiving conventional hemodialysis. In this review, we identify a number of differences in vascular access–related outcomes across the range of specified comparisons. Collectively, these observations can inform the development of dedicated clinical practice guidelines for intensive hemodialysis, but also serve to identify many areas of uncertainty and priorities for future research.

Acknowledgements

Support: This study was supported with a grant from the Canadian Society of Nephrology (CSN). The CSN grant review committee made a number of suggestions, including the use of GRADE for the actual Clinical Practice Guidelines. Dr Brenda Hemmelgarn for the CSN grant review committee also provided mentorship throughout the project. This research also was funded in part by The Canadian Institutes of Health Research (Meeting Planning and Dissemination grant FRN #106165).

Financial Disclosure: The

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