Should the HD (Hemodialysis) catheter be removed from a patient with ESRD (End-Stage Renal Disease) undergoing hemodialysis via a left AVF (Arteriovenous Fistula)?

Remove the HD Catheter Immediately Once the AVF is Functional

Yes, remove the hemodialysis catheter as soon as possible once the left arteriovenous fistula (AVF) is mature and functional. This recommendation is based on the significantly higher mortality, infection risk, and complications associated with catheter use compared to AVF access in ESRD patients 1.

Rationale for Immediate Catheter Removal

Superior Outcomes with AVF Access

• AVF has the lowest infection risk, longest patency rates, and lowest all-cause mortality compared to catheters or grafts 2
• Central venous catheters (CVCs) are associated with the greatest risk of infection-related and all-cause mortality among all vascular access types 2
• Guidelines recommend arteriovenous access (AVF or AVG) over tunneled CVCs for all ESRD patients receiving hemodialysis 1

Specific Risks of Prolonged Catheter Use

• Systemic and local infections occur more frequently with cuffed catheters than with AV accesses 1
• Central venous stenosis risk increases with catheter duration, which can preclude future permanent vascular access establishment 1
• Lower blood flow rates with catheters can compromise dialysis adequacy, which is associated with increased morbidity and mortality 1
• Catheter-related mortality is well-documented and represents a preventable cause of death in dialysis patients 2

Timing Considerations

AVF Maturation Requirements

• A primary AVF should mature for at least 1 month, ideally 3-4 months before cannulation 1
• The AVF is considered mature when the vein diameter is sufficient for successful cannulation 1
• If the provider has indicated the AVF is ready for use, the catheter should be removed promptly 1

Catheter Duration Limits

• Less than 10% of chronic maintenance hemodialysis patients should be maintained on catheters as permanent access 1
• Chronic catheter access is defined as use exceeding 3 months in the absence of a maturing permanent access 1
• Catheters should not be inserted until hemodialysis is needed, and should be removed once permanent access is available 1

Clinical Algorithm for Catheter Removal

Step 1: Verify AVF Functionality

• Confirm adequate vein diameter for cannulation 1
• Ensure the AVF has been in place for at least 1 month (preferably 3-4 months) 1
• Verify adequate blood flow rates can be achieved through the AVF 1

Step 2: Remove Catheter Promptly

• Remove the catheter on the same day or within 24-48 hours of confirming AVF functionality to minimize infection and stenosis risk 1, 2
• Do not delay removal waiting for "backup" access, as this increases complication rates 1, 2

Step 3: Monitor Post-Removal

• Assess AVF function during initial dialysis sessions 1
• Monitor for any signs of AVF failure requiring intervention 1

Common Pitfalls to Avoid

Avoiding Unnecessary Catheter Retention

• Do not keep the catheter "just in case" the AVF fails—this practice significantly increases infection and mortality risk 1, 2
• Patient reluctance to remove the painless catheter access should be addressed through education about infection and mortality risks 1
• The ease-of-use of catheters can foster inappropriate long-term reliance despite greater risks 1

Protecting the AVF Site

• Avoid venipuncture and IV catheters in the arm with the AVF to preserve the access 1
• Instruct all hospital staff to protect the AVF arm from any venous access 1
• Consider a Medic Alert bracelet to inform staff about access preservation 1

Special Consideration: Subclavian Catheters

• If the current catheter is subclavian, removal is even more urgent due to high risk of central venous stenosis that can preclude future ipsilateral arm access 1

Quality Metrics

• Dialysis centers should maintain catheter use rates below 10% of chronic maintenance patients 1
• After adjusting for initial failures, AVF thrombosis rates should be less than 0.25 episodes per patient-year 1