Opponent's comments

We agree with many of the points raised in Dr Nesrallah's polar views paper: (i) the early enthusiasm for and uptake of buttonhole cannulation occurred in the absence of any high-quality evidence evaluating its safety and efficacy; (ii) an increased risk of bacteremia has been consistently observed with buttonhole cannulation; (iii) it remains uncertain whether the strategies outlined by Dr Nesrallah will successfully mitigate this heightened infection risk; (iv) there is no high-quality evidence supporting any benefit of buttonhole cannulation and (v) buttonhole cannulation is declining in many jurisdictions globally because of safety concerns. We also absolutely agree with Dr Nesrallah regarding the importance of patient satisfaction and well-being as clinical outcomes that should receive greater attention in dialysis practice and research. Unfortunately, we do not consider buttonhole cannulation as a true improvement from a patient's point of view. Indeed, and as recognized by Dr Nesrallah, one of the most important patient-relevant outcomes, cannulation-related pain, was not significantly improved in a well-designed Canadian randomized controlled trial (RCT) [1]. Likewise, evidence of potentially improved vascular access survival with buttonhole cannulation mostly relied on one RCT [2], which demonstrated a high risk of attrition bias as well as a higher rate of abandonment in the buttonhole arm. Other RCTs do not support any vascular survival benefit of buttonhole cannulation. Furthermore, recent randomized studies have not demonstrated any clear benefit of buttonhole cannulation with respect to hematoma formation, hemostasis, vascular access intervention or aneurysm formation [1–5]. Interestingly, home hemodialysis patients were cited as a specifically targeted population for buttonhole cannulation in Dr Nesrallah's position paper, reflecting an ingrained belief held by a number of proponents that buttonhole cannulation facilitates home hemodialysis recruitment by increasing a patient's confidence in performing self-cannulation. While this unsubstantiated belief is strongly anchored in numerous home dialysis programs, conversion from buttonhole to rope-ladder cannulation was successfully performed by many home dialysis programs in Australia without an observed decline in their home hemodialysis populations [6]. Finally, we agree with Dr Nesrallah that buttonhole cannulation could still be used in the context of well-conducted randomized controlled studies with infection control strategies or for very selected patients for whom standard cannulation technique has proven unsuccessful due to specific anatomical constraints. Nevertheless, apart from these limited, specific situations, we do not consider buttonhole cannulation as a suitable cannulation approach in either in-center or home hemodialysis patients, as patient safety should never be jeopardized on the basis of uncertain, unproven benefits.

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