“Catheters are not nearly as bad as we make them out to be.” This was one of the salient messages delivered by Theodore Saad (Nephrology Associates, Newark, USA) at the 2022 Vascular Access for Hemodialysis Symposium (9–11 June, Charleston, USA). In a presentation based primarily around patients’ stories of their experiences on dialysis, he also noted that much of the data suggesting high infection rates and poor outcomes with access catheters are uncontrolled and outdated—and there are select patients for whom a long-term catheter turns out to be their best option. Renal Interventions later caught up with Saad to expand on some of these themes.
“No matter how you slice it, dialysis is something of a burden to most, if not all, patients,” Saad avers. “And, patients deal with that burden very differently depending on their health status, their personal circumstances, their family support, their living situation etc. We [physicians] sometimes forget or lose sight of how much of a burden it is because we see it every day but, from the patients’ side of things, it can be daunting, it is a burden, and it can be consuming.”
“From a patient’s perspective, when it comes to their vascular access, they just want it to work,” he continues. “They want it to be painless, reliable and effective, and they do not want to have to worry or think about it. They just want it to be there and for it to work.” Saad also suggests that being able to de-access, achieve haemostasis and go home quickly with no complications is another priority for the patient. “Anything that works against that is a negative for them,” he says. “Dialysis is tough enough as it is without having a struggle getting into [and out of] the access.”
“Some patients are far more tolerant and accepting of what needs to be done to maintain their access than others,” Saad adds. Here, he notes that he sees a wide spectrum of attitudes within his own practice, as some patients will get “very upset or even hostile” if anything needs to be done to their access, even if they are only going in for revisions roughly once per year. Conversely, other patients require multiple revisions each year to maintain a very delicate fistula, but are fully aware that it likely represents “the best access they are ever going to have”, and as such they and their families are “absolutely delighted” just to have it working.
Fistula, graft or catheter?
At Saad’s centre in Delaware, the split between the major vascular access options for dialysis is fairly consistent with other high-quality practices around the country. “We start most of our patients [60–80%] with catheters—more than we would like,” he says. “We are tracking and monitoring our patients to try to improve on that and achieve the optimal permanent starting access but, still, the majority start with catheters.” Close to 20% of prevalent patients remain on long-term catheters, he states, while 60–65% receive fistulas and the rest (roughly 20%) receive grafts. “That is a pretty reasonable mix, I think, in 2022,” Saad adds.
“If I go back over the past 30 years, I have seen access patterns go from largely fistulas and few catheters, to largely grafts and few fistulas, to lots of catheters and lots of grafts, to now—where we have a high proportion of fistulas,” Saad continues. He also notes there is some evidence that the implementation of ‘fistula-first’ guidance led to increased catheter rates in the past and, more recently, COVID-19 has negatively impacted efforts to bring catheter rates down by restricting or delaying access to elective surgical procedures.
Saad then reiterates that, rather than having an overwhelming preference for any of these individual access options, “the patients want something that works—whether that is a fistula, a graft or a catheter”. If a patient has had negative experiences on one or two of the other distinct access options, but is currently doing well on another, they are far more likely to favour continuing with whatever has served them best, Saad asserts. This could be seen to reflect the shift away from ‘fistula-first’ towards ‘the right access’ in the 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) guideline update.
According to Saad, the worst access option for patients and clinicians alike is a “bad” fistula. A fistula that cannot be easily or reliably cannulated, causes the patient a lot of pain, requires multiple interventions and, ultimately, does not provide for adequate dialysis is “miserable” for the patient, the dialysis team, and the nephrologist, he adds. This is why patients who have had poor experiences with a fistula before going on to do very well with a catheter, for example, tend to favour sticking with the latter. “That is their reality and their perspective—I can give them all the data I want, but if they have a catheter that is working perfectly and I tell them I want to try another fistula [when their first fistula failed despite repeated intervention], that is a hard sell,” Saad says. “Patients will fail to accept that illogic; they have limited tolerance for failure and for futility.”
In terms of striking a balance between what the data would dictate and what the patient wants based on their experiences, Saad believes ‘forward progress’ is key. “That goes a long way to persuading a patient to stick with a programme and see the light at the end of the tunnel,” he continues, noting that multiple successive fistula interventions can be justified as worthwhile—again, for both the patient and the physician—provided each procedure is improving outcomes and increasing the likelihood of long-term success. “But, to be repeatedly intervening on a fistula and seeing things get worse rather than making that forward progress is, I think, the ultimate futility,” Saad asserts.
Based upon his experiences as a nephrologist and feedback from his own dialysis patients, Saad concludes that the optimal treatment modality cannot be selected, and dialysis access decisions more generally cannot be made, using a ‘one-size-fits-all’ approach. “It is essential to listen to patients; understand their goals and priorities; appreciate the impact of dialysis on their lives; and, ultimately, support their reasoned, informed choices,” he adds.