Haemodialysis continues to be the Renal Replacement therapy of choice in End Stage Renal Disease Patients. Vascular access is an integral and important aspect for ESRD patients being started on Chronic Haemodialysis treatments.  Preliminary data from the Dialysis Outcomes and Practice patterns showed that 14 % of patients in Europe and 34 % of patients in the United States start dialysis with an Acute Dialysis Catheter. The prevalence of Acute Catheters in Chronic HD patients is 4 and 15 % respectively in Europe and the United States. Patients referred late for Dialysis are more likely to begin Dialysis using an Acute Dialysis Catheter.(1)Despite the continuous improvement of dialysis technology and pharmacological treatment, mortality rates for dialysis patients are still high. Cardiovascular death and infections remain the leading cause of mortality in Dialysis populations.(2,3)

There is inadequate evidence for the KDOQI to make any recommendations on incident vascular access. The evidence for the associations between mortality and all cause hospitalizations and incident vascular access is also inadequate. KDOQI considers it reasonable to use tunnelled central venous catheter (CVC) in preference to non-tunnelled CVC due to the lower infection risk with tunnelled CVC.(4) These statements while valid however present a problem in real time management in low income countries where patients are often unable to afford the necessary costs required for inserting a tunnelled central venous catheter. In a study done in Nigeria that prospectively followed the outcomes of Internal Jugular Vein Catheterization with both tunnelled and non-tunnelled catheters, a non-tunnelled catheter could be used for a duration of 1-8 weeks with catheter related bacteraemia being the limiting factor for removal.(5)Another Study done in Canada prospectively followed patients with un-cuffed Internal Jugular Catheters inserted for dialysis purpose and reported only 5.4 % incidence in bacteraemia after 3 weeks of usage.(6) This was against the KDOQI guideline at the time which recommended catheter usage for 21 days at the Internal Jugular Site. Current KDOQI guidelines recommend CVC usage at the Internal Jugular site for less than 2 weeks. This recommendation however is largely based on expert opinions and there are no large prospective studies done to study risk of bacteraemia and catheter removal rates in the haemodialysis population.

More than 65% of patients of chronic kidney disease (CKD)present as end-stage renal disease (ESRD) to  nephrologists in India.(7) Hence it is difficult for any systematic planning in ESRD patients to be done for a Permanent Vascular Access. Majority of patients often start dialysis on an emergency basis either with Jugular or Femoral un-cuffed catheters with a permanent vascular access planned later after stabilization of their clinical status. As such a number of Patients in the low-income group are unable to afford placement and care of Tunnelled Jugular Catheters which come at a much higher price than non-tunnelled Catheters. With the market cost of Tunnelled Jugular Catheters ranging from 7000 to 32,000 Rupees, along with the cost of medication and investigations the financial burden on a CKD 5D patient from a lower income group is substantial. Non Tunnelled Jugular catheters on the other hand are relatively cheaper within the price range of 1200 – 1800 Rupees placing less of a financial burden on poor patients. Therelative risk of(1) TVC’s causing bacteraemia in patients is approximately ten times higher than the risk of bacteraemiain patients with AV fistula. (7)The risk of infection-related hospitalization/mortality is 2–3 fold higher with TVC’s incomparison to AV  Fistula.(8)The cumulative risk of CRBSI was 35% at 3 months and 48% at 6 months in one study.(9)Studies have also shown that Non Tunnelled Hemodialysis Catheters have a 5 fold greater risk of infection than Tunnelled Hemodialysis Catheters.(10,11) Considering the high risks of CRBSI along with the cost for Tunnelled IJV Catheters, it is imperative to have a lower cost solution as dialysis access for this population group which provides adequate dialysis for Patients till the time an AVF is constructed and matures.

This Study Aims to compare Catheter related Outcomes between Tunnelled and Non Tunnelled IJV Catheters in terms of Catheter Removal Rates and AVF construction. The Aim being to prove that Non Tunnelled Jugular Catheters can be a low cost stable vascular access for more than2 weeks for a patient awaiting AVF construction and maturation and become a viable option for low income group patients in India who cannot afford Tunnelled Jugular Catheters for Dialysis.

REFERENCES

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4.             Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. American Journal of Kidney Diseases. 2020 Apr;75(4):S1–164.

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8.             Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S, et al. Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients. American Journal of Infection Control. 2004 May;32(3):155–60.

9.             Lee T, Barker J, Allon M. Tunneled Catheters in Hemodialysis Patients: Reasons and Subsequent Outcomes. American Journal of Kidney Diseases. 2005 Sep;46(3):501–8.

10.          Vats HS. Complications of Catheters: Tunneled and Nontunneled. Advances in Chronic Kidney Disease. 2012 May;19(3):188–94.

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12.          Mendu ML, May MF, Kaze AD, Graham DA, Cui S, Chen ME, et al. Non-tunneled versus tunneled dialysis catheters for acute kidney injury requiring renal replacement therapy: a prospective cohort study. BMC Nephrol. 2017 Dec;18(1):351–7.