Temporary vascular access for first dialysis is common, undesirable and usually avoidable

When technically feasible, patients with end-stage renal failure should commence regular dialysis treatment with permanent access to the circulation (by arteriovenous fistula) or peritoneum (by soft peritoneal catheter) in situ, thus avoiding the need for initial hemodialysis employing temporary vascular access. We have examined the frequency, consequences and avoidability of temporary access in such patients.

178 patients commencing regular dialysis between August 1993 and April 1995 were analysed retrospectively using case notes. Patients were divided into those who had permanent dialysis access in situ when they commenced dialysis and those who required temporary access. If temporary access was required, the patients were further analysed into those who had been first seen by a nephrologist at least 12 weeks before the first dialysis, and those who had been referred "late". It was assumed that 12 weeks was sufficient time for permanent access to be instituted. Mortality within the first 90 days of commencing dialysis was recorded.

Seventy-four of 82 patients opting for regular hemodialysis and 53 of 96 opting for peritoneal dialysis required temporary vascular access. Late referral accounted for 47 and delays within the renal service for 35 of such patients. Late presentation to the medical profession or indecisiveness on the part of the patient accounted for the remainder. Twenty-five of 127 patients requiring temporary access but only one or 51 patients not requiring it died within 90 days of commencement of treatment.

Late presentation to a renal unit prior to first dialysis is associated with increased mortality. Late referral or late presentation are associated with an increased need for temporary vascular access for first dialysis. Many patients who require temporary access for first dialysis could have been better managed.