MINI-REVIEW

Ethical and Legal Obligation to Avoid Long-Term Tunneled Catheter Access

Raheela Rehman ^*, Rebecca J. Schmidt ^*, and Alvin H. Moss ^*1

*Section of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia; Center for Health Ethics and Law, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia

¹ To whom correspondence should be addressed. E-mail: amoss{at}hsc.wvu.edu.

	Abstract

Background and objectives: Despite recent national initiatives promoting the arteriovenous fistula as the initial, primary, and sole vascular access to be used by hemodialysis patients and recommending a decrease in the prevalence of tunneled cuffed catheters to less than 10%, the prevalence of tunneled cuffed catheters as hemodialysis access is increasing. This study describes the risks of tunneled cuffed catheters, explores the reasons why they remain prevalent, and presents the stance that nephrologists have an obligation to offer tunneled cuffed catheters only for temporary use and not as an acceptable alternative for long-term vascular access to patients for whom a properly functioning arteriovenous fistula or graft is possible.

Design, setting, participants, & measurements: The authors formulated recommendations for tunneled cuffed catheter use based on dialysis clinical practice guidelines and the medical evidence regarding outcomes of use of arteriovenous fistulas and tunneled cuffed catheters.

Results: Compared with dialysis with arteriovenous fistulas, long-term dialysis with tunneled cuffed catheters is associated with (1) two to threefold increased risk of death, (2) a five to 10-fold increased risk of serious infection, (3) increased hospitalization, (4) a decreased likelihood of adequate dialysis, and (5) an increased number of vascular access procedures.

Conclusions: To adequately inform patients about access options, nephrologists are ethically obligated to systematically explain to patients the harms of tunneled cuffed catheters. If catheters must be used to initiate dialysis, nephrologists should present catheters only as temporary and unsafe for long-term use.