Replacement Strategies for Tunneled Hemodialysis Catheters with Complications: A Nationwide Cohort Study

Clin J Am Soc Nephrol. 2024 Jun 24. doi: 10.2215/CJN.0000000000000495. Online ahead of print.

Abstract

Background: Tunneled hemodialysis catheters often have infectious or mechanical complications that require unplanned removal and replacement, but the optimal replacement strategy is unknown. This study described the real-world use of two strategies in Australia and compared the survival of replacement catheters inserted by either strategy.

Methods: Observational data from the REDUCCTION trial, which enrolled a nationwide cohort of 6400 adults who received an incident hemodialysis catheter (2016-2020) was used for this secondary analysis. Tunneled catheters were replaced by either catheter exchange through the existing tunnel tract or removal and replacement through a new tract. The effect of the replacement strategy on the time to catheter removal due to infection or dysfunction was estimated by emulating a hypothetical pragmatic randomized trial among a subset of 434 patients with mechanical tunneled catheter failure.

Results: Out of 9974 tunneled hemodialysis catheters inserted during the trial, 380 had infectious and 945 had mechanical complications that required replacement. Almost all infected hemodialysis catheters (97%) were removed and separately replaced through a new tunnel tract, whereas nephrology services differed widely in their replacement practices for catheters with mechanical failure (median = 50% guidewire exchanged, interquartile range= 30%-67%). Service-level differences accounted for 29% of the residual variation after adjusting for patient factors. In the target trial emulation cohort of mechanical failure (N=434 patients), catheter exchange was not associated with lower complication-free survival at one, six, or 12 months (counterfactual survival difference at one month = 5.9%, 95% CI = -2%, 14%).

Conclusion: Guidewire exchange for mechanical failure of catheter was not associated with lower catheter survival and may be preferable for patients.