Figure 56

Trends in dialysis access sites. Despite our understanding of hemodialysis access and the advantages and disadvantages of the various options available, there is an alarming trend away from the use of native vein fistulas. Of even more concern is the increasing number of patients who begin dialysis without a permanent vascular access in place and the increasing prevalence of central vein catheters. It is not clear whether these trends are the result of age, comorbid conditions such as diabetes and peripheral vascular disease, or simply the untoward effect of late nephrology referral. Although central vein catheters were initially designed for temporary use while an arteriovenous vascular access was being constructed, improvements in design have led to their being used for permanent dialysis access. Nevertheless, central vein catheters, while popular with patients because they obviate "being stuck," are the source of a variety of access complications, including infection, central vein stenosis, and thrombosis.

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