[Access for starting kidney replacement therapy: vascular and peritoneal temporal access in pre-dialysis]

PATIENT EVALUATION AND PREPARATION PRIOR TO VASCULAR ACCESS (VA) PLACEMENT: 1. Early referral of patients with advanced chronic kidney disease (ACKD: GFR

They should not be the first option for a permanent VA and should be considered for temporary use only whenever possible. Their main indications are: - Need for urgent HD in patients without permanent VA, patients with a maturing VA or that cannot be cannulated (Strength of Recommendation A). - Inability or difficulty to establish an adequate VA due to either a poor arterial bed or lack of venous development (Strength of Recommendation B). - Hemodialysis for short periods while waiting for a living donor kidney transplant (Strength of Recommendation C). - Patients with special circumstances: very severe comorbidities that imply a life expectancy of less than 1 year, cardiovascular status contraindicating placement of VA, PD patients temporarily on HD, etc. (Strength of Recommendation C). 2. Types of CVC: Selection of the type of catheter should be based on local experience, the patient's individual circumstances and the requirements for its use. - Nontunneled CVC should be reserved for stays < 3 weeks due to their higher rate of complications (Strength of Recommendation B). - Intravascular lengths of 15 cm are recommended in the right jugular vein, 20 cm in the left jugular vein, and 20-25 cm in the femoral veins (Strength of Recommendation B). 3.

- The first choice is the right internal jugular vein, followed by the left internal jugular vein, the external jugular vein and the femoral veins. The subclavian veins should only be used exceptionally (Strength of Recommendation A). - Placement of a CVC ipsilateral to a maturing AV fistula should be avoided (Strength of Recommendation B). The use of femoral catheters should be limited to hospitalized (bedridden) patients (Strength of Recommendation B) because they are associated with higher infection and dislodgement rates. - The tip of the CVC should be placed at the entry of the right atrium for nontunneled catheters and within the right atrium for tunneled catheters (Strength of Recommendation B). Placement of CVC in the jugular and subclavian vein should be confirmed radiologically (Strength of Recommendation A). TYPES OF CATHETER AND IMPLANTATION TECHNIQUES: - The implantation team (nephrologist, surgeon, nurse) is more important for results than the technique of implantation used (Strength of Recommendation A). - No catheter has been demonstrated to be superior to others (Strength of Recommendation A). - Surgical, laparoscopic or percutaneous technique show similar results (Strength of Recommendation A). TIMING OF CATHETER IMPLANTATION: - Between catheter insertion and the start of peritoneal dialysis (PD) at least two weeks should be allowed to avoid early leaks (Strength of Recommendation C). - Antibiotic prophylaxis should be performed prior to the implantation procedure (preferably a 1st generation cephalosporin) (Strength of Recommendation A). EARLY COMPLICATIONS AND THEIR TREATMENT: - Prevention of exit site infections: It is mandatory to identify Staphylococcus aureus nasal carriers and treat them with mupirocin ointment either intranasal or pericatheter, or gentamycin pericatheter, to reduce the incidence of infections by this germ (Strength of Recommendation A). - Treatment of exit site infections: Treatment should conform to the PD guidelines published by the SEN. Withdrawal of the catheter due to exit site infection should be considered when there is concurrent peritonitis by the same germ (except coagulase-negative staphylococcus) or treatment-refractory or recurrent infections by the same germ (Strength of Recommendation C). - Mechanical complications: If leakage of peritoneal fluid occurs and dialysis is necessary, the patient should be temporarily transferred to HD or started on automatic peritoneal dialysis (APD) with low volumes and in a decubitus position.