Dialysis Catheters: Types, Care, Complications & When They're Used

Types of dialysis catheters

Non-tunneled (temporary) catheters: placed at the bedside, usually in the internal jugular or femoral vein, used for days to a few weeks. They are the emergency option — for urgent dialysis starts, acute kidney injury in the ICU, or poisonings. Because they lack a cuff and tunnel, infection risk is highest.

Tunneled (cuffed) catheters: the catheter passes through a subcutaneous tunnel with a cuff that anchors it and blocks bacterial migration. These last weeks to months and are the standard bridge while a fistula matures or a patient awaits transplant. Examples: Tesio, Ash Split Cath, Palindrome.

Insertion sites matter: the right internal jugular vein is preferred (straightest path to the right atrium). The femoral vein is used short-term but has high infection and thrombosis rates. The subclavian vein is AVOIDED for dialysis catheters because it causes central venous stenosis that permanently ruins the arm for future fistula creation.

Care and hygiene

Catheter care is a strict protocol: sterile dressing changes, chlorhexidine skin cleansing, catheter caps cleaned before each connection, and the exit site examined at every session for redness or discharge. Patients are trained on what to watch for.

The catheter should ONLY be touched by trained staff with sterile technique — it is a direct line into the bloodstream. Showering requires waterproof protection; swimming is not allowed.

Every dialysis session, the staff flush the catheter with saline and lock it with heparin or citrate to prevent clotting between sessions. Exit-site infection (redness, tenderness, pus) is treated immediately — it can escalate to bloodstream infection within days.

Complications

Infection (CLABSI — catheter-related bloodstream infection): the most feared complication. Rates run 1.5-5.5 per 1,000 catheter-days vs 0.3-0.6 for fistulas. Sepsis from catheter infection is a major cause of death in dialysis patients — and each infection adds hospitalization, antibiotics, and often catheter removal.

Central venous stenosis: scar tissue in the vein from the catheter — the reason subclavian placement is avoided and why repeated catheter placements progressively destroy access options.

Catheter dysfunction: poor blood flow from kinking, thrombosis, or a fibrin sheath. It causes underdialysis (missed adequacy) and often needs thrombolytic locks or exchange.

Fibrin sheath and catheter thrombosis: treated with tissue plasminogen activator (tPA) locks; recurrent cases may require catheter exchange over a guidewire.

Why catheters are a bridge, not a destination

The data are unambiguous: patients dialyzing through a catheter have higher mortality than those using a fistula or graft — largely from infection and sepsis. KDOQI 2019 states the access hierarchy clearly: AV fistula first, AV graft second, catheter last.

About 80% of US patients start dialysis with a catheter because urgent starts leave no time for fistula creation. The standard of care: create the fistula (or refer for it) as early as possible — ideally at eGFR 20-30 in CKD, months before dialysis — and transition off the catheter once it matures.

The 'fistula first' strategy prevents most catheter-related harm, which is why vascular access planning is one of the highest-value interventions in nephrology.