walaikum wassalam. First of all it is important for you to know the condition of the patient and the diagnosis as patient has a complex of diseases. Patient has hypertension induced Renal failure and hypertension induced heart failure. The reports suggest that patient has advance renal failure and the residual function of kidney is less than 10 %. As you have mentioned that the main problem of the patient is shortness of breath. the causes of shortness of breath are as follow: A) As the patient has an HB of 5.5 which is of course dangerously low. This low haemoglobin is due to non functioning kidneys. Basically the chemical that causes blood formation in the bone marrown is derived from the kidneys. When kidneys lose its function the blood formation reduces significantly which cause Anemia(low Hb). This low HB results in shortness of breath because of the low oxygen carrying capacity of the blood to deliver oxygen to the body tissues. B) Heart failure is another cause of the shortness of breath. Heart functions as a pump that pushes the blood towards the tissue. Decline in heart function leads to Inadequate supply of blood to the tissue which cause shortness of breath and also the blood starts to pool in the peripheral tissues like lungs that also causes shortness of breath. C) Ureamia; patient has a significantly elevated urea and creatinine levels that shows that toxins have not properly eliminated from the body. These toxins in turn virtually disrupt function of every organ of the body. At this particular point of time the most suitable and life saving treatment is of course Haemodialysis. Three times a week is one of the best regimens along side the concomitant treatment for Hypertension and heart failure. Regarding low HB the most suitable treatment would be ESPOGEN( recombinant erythropoietin). This is the chemical that induces blood formation as mentioned earlier on. Patient is already taking it. If economically feasible it would be best if 2000 units be given twice a week subcutaneously. It will have significant impact on both low HB and Shortness of breath. Regarding the catheters it s necessary to know that long term dialysis needs fistula. The dual lumen catheters have a high chance of bacterial infection and are thus used as a temporary bridge to fistula. Formation of fistula to until it works takes up to 2 months. Central venous catheter( used as a bridge to fistula) have two varieties; 1) the first variety are temporary catheters that passed directly to central veins and are thus easy to use but have high rate of infection and less half life. 2) Permanent catheters that are passed into the central veins via a tunnel in the skin. The chances of infection are low and half life is more but these require high skill to pass and are costly. Thus if the patient has already one failed surgery procedure, it s better to use a permanent Catheter(the second variety) and then try for a second fistula surgery and if the surgery gets successful then remove catheter and proceed further with fistula. I hope you find this helpful. regards. Dr.Abdur Rehman Alozai.