Comparing Catheters with Fistulas in Older Patients Starting Hemodialysis: A Pilot Randomized Controlled Trial.
Older patients who began haemodialysis with a catheter were randomly assigned either to attempt fistula creation or to keep the catheter. Most patients declined randomisation because they preferred their catheter, and the catheter group did not fare worse over follow-up.
Background
Arteriovenous fistulas have historically been the guideline-preferred haemodialysis access because observational studies linked them to better clinical outcomes and lower costs. However, catheters and fistulas have never been compared head-to-head in a randomized trial, so the evidence base carries a substantial risk of selection bias — sicker patients are less likely to receive a fistula in the first place.
Study design
Investigators ran a pilot randomized controlled trial across 12 haemodialysis centres in Canada and Australia. Patients aged 55 years and older who started haemodialysis using a tunnelled or non-tunnelled central venous catheter were randomized either to an attempt at fistula creation or to continued use of a tunnelled catheter. The primary outcome was feasibility: the proportion of eligible patients consenting to randomization, and the proportion in the fistula arm who underwent fistula placement within 90 days.
Key findings
Of 1287 patients screened, 67 underwent randomization. Only 25% of eligible patients agreed to be randomized, and 71% of those assigned to the fistula arm received a fistula within 90 days. The most common reason for declining was a stated preference to continue dialysing with the catheter. Patients randomized to fistulas had nominally more access-related interventions, more hospitalizations and more bacteraemia (most of it catheter related), while the catheter group relied more on thrombolytic therapy.
Clinical implications
The authors conclude that a definitive randomized trial of fistulas versus catheters is not feasible in the current climate. For practice, the strength of patient preference documented here reinforces that vascular access selection in older patients should be an explicit shared decision rather than a default, and that the absence of any harm signal from a catheter strategy in this population deserves weight in that conversation.
Category
Research
Source
Journal of the American Society of Nephrology
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