Balancing Fistula First with Catheters Last.

Area of Science:

• Nephrology
• Vascular Surgery

Background:

• The Fistula First initiative successfully increased arteriovenous fistula use for hemodialysis.
• This success has been linked to an unintended rise in hemodialysis catheter use.
• Prolonged catheter use is associated with significant morbidity, mortality, and healthcare costs.

Purpose of the Study:

• To propose a revised national vascular access strategy.
• To integrate the goals of increasing fistula use and decreasing catheter dependence.
• To address the complications associated with prolonged hemodialysis catheter use.

Main Methods:

• Synthesis of existing guidelines, reviews, and published evidence.
• Incorporation of expert opinion from authors.
• Analysis of the impact of the Fistula First initiative on vascular access trends.

Main Results:

• The national focus on fistulas may have diverted attention from reducing catheter use.
• A dual goal strategy, "Fistula First and Catheters Last," is recommended.
• Interventions promoting early fistula placement and avoiding extended catheter use are crucial.

Conclusions:

• The ideal hemodialysis vascular access involves early fistula placement with adequate maturation time.
• Reimbursement policies supporting pre-emptive permanent access placement are essential.
• Individualized strategies, including peritoneal dialysis or bridge grafts, should be considered to minimize catheter use.