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Dialysis catheters provide vascular or peritoneal access for renal replacement therapy across the spectrum of acute kidney injury, advanced chronic kidney disease, and established end-stage kidney disease. Hemodialysis catheters deliver high extracorporeal blood flow rates, whereas peritoneal dialysis catheters enable dialysate instillation and drainage within the peritoneal cavity. Understanding variations in anatomy and associated complications is crucial for the ideal functioning of both hemodialysis and peritoneal catheters. Although necessary for renal replacement therapy, both types of catheters have associated complications. This activity reviews current best practices in catheter selection, image-guided insertion, tip positioning, and maintenance. This activity also examines major complications, including dysfunction, infection, and central venous stenosis, and outlines evidence-based prevention strategies such as lock solutions, care bundles, and exit-site management. Emphasis is placed on individualized access planning guided by the ESKD Life-Plan and on the interprofessional processes required to optimize catheter performance and patient outcomes. Objectives: Apply best-practice techniques for ultrasound-guided internal jugular hemodialysis catheter insertion, ensuring optimal catheter length, accurate tip position, and confirmation using fluoroscopic or ECG-based methods. Differentiate absolute and relative contraindications to hemodialysis and peritoneal dialysis catheter placement and integrate this knowledge into clinical decision-making for individualized patient care. Identify common catheter complications—such as dysfunction, infection, fibrin sheath formation, central venous stenosis, exit-site infections, and peritonitis—using contemporary evidence-based strategies, including antimicrobial or antiseptic lock solutions and standardized maintenance bundles. Implement interprofessional strategies to enhance catheter longevity, reduce infection risk, and incorporate dialysis access planning into the patient’s individualized ESKD Life-Plan to minimize unnecessary catheter dependence. Access free multiple choice questions on this topic.

Dialysis catheters provide access for renal replacement therapy by enabling extracorporeal blood purification or peritoneal dialysate exchange. Two principal categories are used clinically: Extracorporeal renal replacement therapy catheters (hemodialysis catheters): Large-bore central venous catheters designed for high flows, typically 300 to 450 mL/min, used in hemodialysis, hemofiltration, hemodiafiltration, or ultrafiltration. Depending on the anticipated duration of renal replacement therapy, these catheters may be non-tunneled (temporary) or tunneled, cuffed (longer-term). The cuff in tunneled lines promotes tissue ingrowth and lowers infection risk compared with non-tunneled lines.[1] Peritoneal dialysis catheters (eg, Tenckhoff catheters): Soft silicone catheters with 1 or 2 cuffs enabling dialysate exchanges within the peritoneal cavity.[2] Current best practice emphasizes image-guided insertion, meticulous maintenance, and individualized access planning guided by the End-Stage Kidney Disease Life Plan (ESKD Life Plan)—a Kidney Disease Outcomes Quality Initiative (KDOQI) 2019 concept aligning access choices with patient preferences, prognosis, and modality trajectory.[3]

Hemodialysis Catheters Mechanical complications: Mechanical complications include arterial puncture, hematoma, malposition, arrhythmias, pneumothorax/hemothorax (subclavian/internal jugular), and air embolism. The risk of these complications is reduced by ultrasound and image-guided insertion techniques.[5] Dysfunction: Dysfunction may result from kinking, malposition, thrombus, or fibrin sheath formation around the catheter. Interventions include temporary line reversal, exchange over a wire, balloon disruption of a fibrin sheath (first-line in many centers), formal fibrin-sheath stripping for refractory cases, or catheter replacement.[13] Infection: Catheter-related bloodstream infection (CRBSI) should be defined using CDC or KDOQI criteria to standardize diagnosis and reporting. CRBSIs and exit-site or tunnel infections increase hospitalization and mortality. Recent data on modern symmetric-tip non-side-hole tunneled catheters report CRBSI rates of approximately 0.76 per 1000 catheter-days, suggesting that updated catheter designs may modestly reduce infectious risk.[14] Evidence supports the use of comprehensive catheter care bundles, antimicrobial or antiseptic lock solutions—either antibiotic or non-antibiotic, such as citrate, EDTA, or taurolidine, depending on local policy—and antimicrobial barrier hub caps to reduce CRBSIs. A 2021 meta-analysis showed that both antibiotic and nonantibiotic antimicrobial lock solutions significantly reduce CRBSI compared with heparin. [15] However, recent high-quality randomized evidence found that a multifaceted catheter-care bundle did not significantly reduce CRBSI rates compared with baseline practice, emphasizing the difficulty of achieving further reductions in real-world settings.[16] Central venous stenosis: This complication occurs particularly after subclavian catheterization and may compromise future arteriovenous access. Angioplasty can restore patency, although recurrence is common.[6][3] Peritoneal Dialysis Catheters Complications include bowel or bladder injury (rare, approximately 1% perforation), leaks, hemorrhage, malposition, omental wrapping, adhesions, and catheter blockage. Isotonic irrigation or urokinase may restore flow; forceful irrigation should be avoided to prevent catheter perforation or damage. Refractory cases may need laparoscopy and omentectomy.[17][10]

Complications include bowel or bladder injury (rare, approximately 1% perforation), leaks, hemorrhage, malposition, omental wrapping, adhesions, and catheter blockage. Isotonic irrigation or urokinase may restore flow; forceful irrigation should be avoided to prevent catheter perforation or damage. Refractory cases may need laparoscopy and omentectomy.[17][10] Peritoneal dialysis-related infections: Exit-site or tunnel infections and peritonitis remain major complications. The ISPD 2022 peritonitis update provides revised definitions, performance targets (≤0.40 episodes per patient-year; >80% patients per year free of peritonitis), empiric therapy guidance, and training or quality measures; the ISPD 2023 catheter-related infection update clarifies definitions, downgrades routine topical exit-site antibiotics to a context-specific recommendation, and outlines treatment durations and interventions, including cuff shaving or exit-site relocation.[18][19]

Dialysis catheter care is inherently interprofessional, involving nephrologists, interventionalists, surgeons, nurses, pharmacists, and infection-prevention specialists. High-reliability practices include: Ultrasound-guided cannulation and image-guided tip positioning to reduce complications and dysfunction.[3][5][3] Bundles for insertion and maintenance, including maximal barrier precautions, chlorhexidine, hub disinfection, securement, dressing integrity checks, and standardized connection or disconnection, supported by regular auditing and feedback. Annual competency assessment of staff performing catheter manipulation further reduces infection rates.[3] CRBSI prevention strategies, such as antimicrobial lock solutions and, where adopted, antimicrobial barrier caps, aligned with antimicrobial stewardship.[15] Peritoneal dialysis program quality measures include tracking peritonitis and exit-site infection rates against ISPD targets; ensuring staff and patient training with periodic retraining; counseling on hygiene and pet exposure; and prompt response to contamination events.[18][19] When clinicians minimize catheter dependence and adhere to robust infection-control measures, rates of catheter-related hospitalization and CRBSI improve.[3][20] A strategic approach is equally crucial, involving evidence-based strategies to optimize treatment plans and minimize adverse effects. Ethical considerations must guide decision-making, ensuring informed consent and respecting patient autonomy in treatment choices. Each healthcare professional must be aware of their responsibilities and contribute their unique expertise to the patient's care plan, fostering a multidisciplinary approach. Effective interprofessional communication is paramount, allowing seamless information exchange and collaborative decision-making among the team members. Care coordination plays a pivotal role in ensuring that the patient's journey from diagnosis to treatment and follow-up is well-managed, minimizing errors and enhancing patient safety. By embracing these principles of skill, strategy, ethics, responsibilities, interprofessional communication, and care coordination, healthcare professionals can deliver patient-centered care, ultimately improving patient outcomes and enhancing team performance in the management of dialysis catheters.