Comparing Catheters to Fistulas in Older Patients Starting Hemodialysis (ACCESS HD)
Robert R. Quinn, Matthew J. Oliver, Ron Wald, Swapnil Hiremath, Robert P. Pauly, Lisa Miller, Brendan Barrett, Gihad Nesrallah, Martin Gallagher, Sradha Kotwal, Nicholas A. Gray, Hicham C. Hassan, Girish S. Talaulikar, Kevin Thorpe, Janet Graham, Alix Clarke, Jiayi Bian, Jennifer MacRae, Maria Santana, Clara Bohm, Muhammad Mamdani, Sudhir Nagpal, Serdar Yilmaz, Louise Moist, Pietro RavaniBackground:
Fistulas are the preferred form of vascular access and historically, have been recommended by guidelines because they were associated with improved clinical outcomes and costs. However, there has never been a randomized comparison of catheters to fistulas and the evidence on which recommendations were based is observational with potential for bias.
Methods
A pilot randomized controlled trial was conducted in 12 hemodialysis centers in Canada and Australia. Individuals aged 55 years and older who started hemodialysis using a tunneled or non-tunneled central venous catheter for vascular access were randomized to an attempt at fistula creation or continued use of a tunneled, central venous hemodialysis catheter. The primary outcome was feasibility, as measured by the proportion of eligible patients who consented to randomization and the proportion of patients randomized to the fistula group who underwent fistula placement within 90 days. Secondary outcomes included invasive access-related procedures, hospitalizations, access-related infections, tissue plasminogen activator usage, and death.
Results
A total of 1287 patients were screened and 67 patients underwent randomization. A total of 25% of eligible patients agreed to randomization and 71% randomized to the fistula arm underwent fistula placement within 90 days. The most common reason patients declined to participate in the trial was that they preferred to continue to dialyze with their catheter. Patients randomized to fistulas had nominally more access-related interventions, hospitalizations, and bacteremia (the majority of which were catheter-related), while the catheter group experienced greater reliance on thrombolytic therapy.
Conclusions
Findings from this trial suggest that conducting a definitive randomized trial of fistulas versus catheters is not feasible in the current climate. There was no signal of harm associated with randomization to the catheter strategy and most outcomes favored the catheter group. Patients exhibited strong preferences regarding choice of vascular access.