Vascular access for HD and CRRT.

A good functioning vascular access is an essential component for adequate renal replacement therapy (RRT) in acute kidney injury. Tunneled, cuffed catheters are preferred if the anticipated duration of RRT is more than 3 weeks. The right jugular vein is the preferred insertion site for the temporary dialysis catheter (TDC), with ultrasound-guided insertion reducing the risk of mechanical complications. The femoral vein is the second choice, whereas the subclavian vein should be avoided. The most important complications of a TDC are acute malfunction and infection. Intraluminal thrombosis, fibrin sleeve formation, malpositioning and kinking result in acute malfunction. Recirculation can be reduced by correct placement of the catheter and is more an issue for intermittent hemodialysis than for continuous RRT. Strict adherence to simple preventive strategies reduces catheter-related bloodstream infection. In selected patients more sophisticated strategies such as the use of antibiotic/antiseptic impregnated catheters and antibiotic/antiseptic lock solutions may be useful.