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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 3  |  Page : 370-377
Outcome and Survival of Temporary Hemodialysis Catheters: A Prospective Study From a Single Center in Iraq


1 Nephrology and Renal Transplantation Department. Surgical Hospital, Baghdad Medical City, Baghdad, Iraq
2 Nephrology and Renal Transplantation Department, Al-Karamh Hospital, Baghdad, Iraq

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   Abstract 

Background: The use of temporary hemodialysis catheters (THC) has facilitated the delivery of hemodialysis to patients lacking functional vascular access. However, the use of these catheters is often associated with infections or mechanical complications. Methods: A review of experiences at a tertiary referral center in Iraq with the use of 128 THC catheters in 103 patients was undertaken over one year, to identify indications for use and outcomes and issues limiting survival. Results: The indications for insertion of THC included the following: as acute dialysis access for patients with chronic renal failure (CRF) in 42.1%, failed arteriovenous fistulae in 14%, acute renal failure in 18%, failed prior THC in 18.7%, absent vascular access in patients with transplant rejection in 6.2% and severe anasarca in one patient (0.78%). The site of insertion was the right internal jugular vein in 101 patients, the right subclavian vein in 23 patients, and the left internal jugular vein in four patients. During follow-up, 86 catheters were removed: 62 in patients with end-stage renal disease (ESRD), 23 in patients with acute renal failure and one patient with severe anasarca. The reasons for removal of THC in ESRD patients were elective removal (44%), catheter related sepsis (CRS) in 30%, mechanical complications (19%) and others (7%). The subclavian site was associated with infection in 20% of patients, while the internal jugular site was associated with infection in 22.7% of patients. For patients in whom THC removal was for infection, a post removal culture of the catheter tip showed Staphylococcus aureus in 57.8%, Klebsiella in 15.7%, Psuedomonas in 15.7% and Streptococcus hemolyticus in 10.5% of the cases. Conclusions: THC is advantageous for vascular access in patients with acute renal failure. Infections and blockage significantly reduce the survival of THC in patients with ESRD. Approaches to minimize these complications are likely to lead to improved clinical outcomes with THC use.

Keywords: Dialysis Catheter, Haemodialysis, Infection

How to cite this article:
Altaee KA, Theeb OA, Al-Timimi SM, Saeed HM, Alshamma I. Outcome and Survival of Temporary Hemodialysis Catheters: A Prospective Study From a Single Center in Iraq. Saudi J Kidney Dis Transpl 2007;18:370-7

How to cite this URL:
Altaee KA, Theeb OA, Al-Timimi SM, Saeed HM, Alshamma I. Outcome and Survival of Temporary Hemodialysis Catheters: A Prospective Study From a Single Center in Iraq. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Jun 16];18:370-7. Available from: http://www.sjkdt.org/text.asp?2007/18/3/370/33754

   Introduction Top


Acute dialysis catheters are non-cuffed, non-tunneled catheters used for immediate vascular access. They are primarily used for the management of acute renal failure in patients bound to bed-rest and for short­term use in patients with malfunctions at sites of permanent access. Most acute catheters are made of polyurethane, but silicon catheters are now available with larger lumen sizes capable of delivering blood flow rates over 300 ml/min. Acute catheters can be inserted in the internal jugular, femoral or subclavian veins. Intermittent catheter malfunction is known to occur in all types of catheters. [1]

Acute dialysis catheters are vital for achieving immediate vascular access. While their role has lessened with the widespread availability of tunneled dialysis catheters, they are still used primarily in three settings: in bed-bound critically ill patients with acute renal failure, for "in and out" use in patients with temporary loss of permanent vascular access sites, and in ambulatory patients at centers not using tunneled dialysis catheters as an alternative. 2 Preliminary data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) shows that 14% of patients in Europe and 34% of patients in the United States begin dialysis with an acute catheter. [2] The prevalence of use of acute catheters in chronic hemodialysis (HD) patients is 4% and 15% in Europe and the United States, respectively. [3] Analysis of the 1993 U.S. Renal Data System (USRDS) showed that less than 10% of patients used a catheter 30 days after initiating dialysis. By 1996, this number had roughly doubled, such that 19% were using a catheter at the initiation of dialysis and 13% were still catheter-dependent after 60 days. Moreover, in more recent reports, up to 60% of new patients and 30% of prevalent patients were using a catheter for dialysis access. [4]

The present study is a prospective longitudinal cohort study performed in a single tertiary care center that reviews the indications, complications and outcomes of THC, and also identifies the most important factors reducing their efficacy and survival.


   Methods Top


Prospective data were collected on all THC inserted by personnel of the Nephrology-Renal Transplant Department in Specialized Surgical Hospital, Baghdad, Iraq over a period of 12 months extending from June 2004 to June 2005.

Dual-lumen polyurethane non-cuffed non­tunneled HD catheters (Amecath® Ameco medical Industries, Egypt) were inserted under strict asepsis and sutured to the skin. The jugular insertion site was preferred as the first choice followed by the subclavian site. The femoral site was not chosen in any of our patients. Dry dressing was applied and was inspected during each dialysis treatment and changed if required. Catheter lumens were locked with a volume of unfractionated heparin (1000 units/ml) equivalent to the internal volume of the lumen.

The catheter was removed when it was no longer required or when a suspected complication developed. Upon removal, the catheter tips were sent for culture in all cases. Patients who developed significant fever (greater than 38.C) with a HD catheter in situ had their catheters removed if the source of fever was not apparent after clinical examination, and baseline investigations did not reveal any obvious sources of infection.

Catheter complications were determined in the following manner: mechanical cause for removal was defined as poor flow less than 100 ml/min not resolved by patient repositioning or reversal of catheter lumen; catheter related sepsis (CRS) defined by the presence of fever and the isolation of an identical micro-organism from cultures of blood and the catheter tip in the absence of an alternative source; CRS was defined by the presence of fever in the absence of an obvious source of infection with the microbiological criteria being insufficient to diagnose CRS.

The statistical significance of differences in the mean of a continuous outcome variable, which is known or assumed to be normally distributed between two groups, was measured by t-test. The statistical significance of association between two categorical variables was measured by Chi­squared test or by exact tests when the criteria for valid Chi-squared test were not met. An estimate was considered statistically significant if its value was less than 0.05.


   Results Top


A total of 128 HD catheters were inserted in 103 patients (63 male, 41 female) over 12 months (June 2004 to June 2005) in the Nephrology-Renal Transplant Department at the Baghdad Specialized Surgical Hospital, Iraq. The internal jugular vein was used for cannulation in 105 cases; right internal jugular vein in 101 and left internal jugular vein in four; 23 were inserted in the right subclavian vein. During follow-up, 86 THC were removed. The maximum number of catheters in a single individual over the study period was four in two patients who had no alternative dialysis access during the period of the study. The age-range of the patients was 14-73 years with a mean of 33.8 ± 14.1 years. Catheter survival ranged between 1 and 110 days with a mean survival of 35 days in patients with ESRD, while the mean catheter survival in patients with acute renal failure was 20 days.

During follow-up, 86 THC were removed, and the remaining THC were either still in place at the end of the study period, or the patients were referred back to their original dialysis units. In this series, bleeding at the site of catheter insertion was an indication to remove the catheter in two patients while no case of pneumothorax was reported.

Indications for insertion of THC included: absence of vascular access in patients with ESRD in 54 patients (42%), acute renal failure in 23 (18%), failure of previous HD catheter due to infection or non-function in 24 (18.7%), failure of arteriovenous fistula in 18 (14%), absence of vascular access after renal transplant rejection in eight (6.25%) and to control severe fluid overload and pulmonary edema in one patient with moderate renal impairment (0.78%) [Table - 1].


   Catheter Outcome Top


A total of 86 catheters (66 internal jugular sites and 20 subclavian site) were followed­up in this study. The outcome differed according to the indication for insertion. Sixty-two catheters were inserted in patients with ESRD (49 in internal jugular position and 13 in subclavian position), 23 catheters were inserted in patients with acute renal failure (17 in internal jugular and 6 in subclavian position) while in one patient, an internal jugular catheter was inserted to control fluid over load.

Among the 62 THC inserted in patients with ESRD, the indications for catheter removal included elective removal in 27 cases (43.5%); 23 catheters were removed because of mature arteriovenous fistula, and four catheters were removed after successful renal transplantation. Nineteen catheters (30.6%) were removed because of fever and four patients had proven CRS while 15 had possible CRS not responding to antibiotics. Twelve catheters (19.3%) were removed because of obstruction or malfunction (mechanical), one catheter (1.6%) was removed because the patient developed axillary vein thrombosis and three catheters were removed following the death of the patient. (4.8%) [Figure - 1].


   Catheter related sepsis (CRS) Top


Twenty-nine of the 62 catheters inserted in patients with ESRD were complicated by fever in the absence of alternative sources of infection and were considered to have CRS. Parenteral and intra-catheter use of antibiotics was successful in 10 patients. Nineteen catheters (30%) had to be removed to control infection and the catheter tips were sent for microbiological study. Fever subsided after removal of the catheter in all these patients.

Definite CRS was found in four catheters and possible CRS in 15 catheters. The microorganisms isolated included S. aureus in 11 (57.8%), Klebsiella and Pseudomonas in three cases (15.7%) and Streptococcus hemolyticus in two (10.5%). The average time between catheter insertion and development of infection was 43.6 days ranging between 7 and 110 days; 69% of the catheters developed infection after 22 days.

Fifteen of the 66 catheters inserted at the internal jugular site (22.7%) and four of the 20 catheters (20%) inserted at the subclavian site developed infection; the difference was not statistically significant (P < 0.5).


   Discussion Top


Providing adequate HD is dependent largely on having reliable vascular access capable of providing rapid extracorporeal blood flow. Primary arteriovenous fistulae are best suited for providing access to central circulation, and have the lowest rates of infection and thrombosis and thus are the preferred means of access whenever possible. [5] Late referrals to nephrologists make the establishment of arteriovenous fistulae more difficult. Therefore, our reliance on less desirable modes of vascular access such as synthetic (polytetrafluoro­ethylene (PTFE) grafts, tunneled cuffed catheters, and acute vascular access catheters has increased. These modes of access are more prone to both thrombosis and infection. [6]

Double lumen catheters can be inserted into the jugular, subclavian, and femoralveins. [5],[7] They are inserted by a modified Seldinger guide wire technique, thereby minimizing the size of the insertion-induced hole in the blood vessel wall.

In our series, the largest group requiring insertion of new acute HD catheters was the pre-dialysis chronic renal failure group with no vascular access (42%). Late presentation, late referral, and delayed long­term access formation continue to be important indications for the insertion of acute HD catheters in these patients. This demand could be reduced by earlier referral and more timely access creation. The K/DOQI guidelines recommend that patients with chronic kidney disease be referred for surgery for construction of a primary AV fistula when their creatinine clearance is < 25 ml/min and their serum creatinine level is > 4 mg/dl, or within one year of an anticipated need for dialysis. [8]

The second most common indication was for the replacement of a previously failed THC (18.7%). This suggests that efforts to improve THC survival could, in turn, signi­ficantly contribute to fewer subsequent THC insertions. Also, despite their crucial rolein dialysis practices, temporary HD catheters have a high failure rate and high rate of infectious complications.

Catheter related sepsis is important both because it jeopardizes the survival of the HD catheters, but also because of the severity of possible clinical sequelae, including morbidity and possibly mortality. [9] In this study, the internal jugular site was associated with higher risk of infectious complications (22.7%) than the subclavian site (20%) but the difference was not statistically significant (P value < 0.5).

Jeffery et al performed a similar study in 2002 in Australia where they reviewed their experiences involving 205 sequential HD catheters in 93 patients over one year to identify issues limiting survival. Acute vascular access catheters were inserted for acute dialysis access for patients with chronic renal failure (21%), failed grafts or fistulae (18%), acute renal failure (12%), failed chronic ambulatory peritoneal dialysis (8%) or failed prior HD catheters (37%). [10] In comparison with Jeffery's study, the indication to insert THC for CRF patients was significantly higher in our study (42%) (P < 0.005). This is mostly because of late referrals in our patients. Furthermore, Jeffery's study included tunneled cuffed catheters as well as THC, which may explain the higher prevalence of catheters required for failed prior catheters [Figure - 2]. The indications for removal of HD catheters in Jeffery's study were elective in 48%, mechanical complications in 30%, infections in 20%, and other causes in 2%. [10]

Kairaitis et al reported outcomes and complications of THC involving 105 non­tunneled HD catheters, studied for one year. The indications for removal were elective in 40%, mechanical in 10%, infections in 32% and other causes in 8%. [11] Our results were comparable to these studies [Figure - 3].

Infection is the second leading cause of death in dialysis patients, accounting for 12 to 22% of all causes. [5],[6] The source of sepsis in the dialysis population is most often related to vascular access. Powe et al examined a case mix study from the USRDS and found that catheters increased the risk of infection by 50% and synthetic PTFE grafts increased the risk by 33% when compared with native AV fistulae.

There was a high rate of CRS in our study in keeping with previous published reports. [12],[13] Hemodialysis patients have been reported to have a high rate of colonization in nasal and cutaneous flora (50-60%) with S. Aureus. [14],[15] This is reflected in the high rate of S. Aureus infections associated CRS in previous series [12],[13] as well as our own.

Partial or complete catheter occlusion occurs in 20 to 60% of central venous catheters, temporary or tunneled, when inserted for HD. [16] A thrombus in the catheter hub often can be dissolved by local thrombolysis. A thrombus at the tip of the catheter or a fibrin sheath around it, may resist local thrombolysis, if it is not treated by a sufficient concentration of drug. [17] In the present study, 12 catheters (19%) were removed because of obstruction or non­function (mechanical).

In conclusion, vascular access is a basic and essential tool required for renal replacement therapy. Central venous catheters have become the preferred method for vascular access for renal replacement therapy in acute renal failure patients. Catheters provide a rapid and easy form of vascular access, permitting dialysis to be started immediately in critically ill patients. Despite their crucial role in dialysis, these catheters have a high failure rate due to infectious complications. Due to the increased rate of complications associated with the use of HD catheters, effective planning of dialysis access is essential in pre-dialysis patients to minimize the use of these catheters.

 
   References Top

1.Oliver MJ. Acute dialysis catheters. Semin Dial 2001;14:6,432-5.  Back to cited text no. 1    
2.Dykstra DM, Young EW, Goodkin DK, Held PJ. Permanent Vascular Access (VA) procedures and outcomes. J Am Soc Nephrol 2000;10:206A.  Back to cited text no. 2    
3.Arora P, Obrador GT, Ruthazer R, et al. Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol 1999;10:1281-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Tanriover B, Carlton D, Saddekni S, et al. Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies. Kidney Int 2000;57:2151-5.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Fan PY, Schwab SJ. Vascular access: concepts for the 1990s. J Am Soc Nephrol 1992;3:1-11.  Back to cited text no. 5  [PUBMED]  
6.Schwab SJ, Harrington JT, Singh A, Vascular access for hemodialysis. Kidney Int 1999;55:2078-90.  Back to cited text no. 6    
7.Bander SJ, Schwab SJ. Central venous angioaccess for hemodialysis and its complications. Semin Dial 1992;5:121-6.  Back to cited text no. 7    
8.NKF-DOQI Clinical practice Guidelines for Vascular Access. VI .Acute Hemodialysis vascular access Noncuffed catheters. Am J Kidney Dis 2001;37(suppl 1);S145-S81.  Back to cited text no. 8    
9.Saad TF. Bacteremia associated with tunneled, cuff hemodialysis catheters. Am J Kidney Dis 1999;34:1114 24.  Back to cited text no. 9  [PUBMED]  
10.Jeffery A, Chow JS, Suranyi MG. Acute vascular access catheters for hemodialysis: Complications limiting technique survival .Nephrology 2003;8:16-20.  Back to cited text no. 10    
11.Kairaitis LK, Gottlieb T. Outcome and complications of temporary hemodialysis catheters. Nephrol Dial Transplant 1999;14:1710-14.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Almirall J, Gonzalez J, Rello J, et al. Infection of hemodialysis catheters: incidence and mechanisms. Am J Nephrol 1989;9:454-9.  Back to cited text no. 12  [PUBMED]  
13.Dahlberg PJ, Wilfrido R, Yutuc MD, et al, Subclavian hemodialysis catheter infections. Am J Kidney Dis 1986;5:421-7.  Back to cited text no. 13    
14.Yu VL, Goetz A, Wagener M, et al. Staphylococcus aureus nasal carriage and infection inpatient in patients on hemo­dialysis. Efficacy of antibiotic prophylaxis. N Engl J Med 1986;315:91-6.  Back to cited text no. 14    
15.Goldblum SE, Ulrich JA, Goldman RS, et al. Nasal and cutenous flora among hemodialysis patients and personnel: quantitative and qualitative characterization and patterns of staphylococcal carriage. Am J Kidney Dis 1982;2:281-6.  Back to cited text no. 15  [PUBMED]  
16.Powe RA ,Dhingra J, Furth SL, Hermann J. Septicemia in dialysis patients: incidence, risk factors, and prognosis. Kidney Int 1999;55:1081-90  Back to cited text no. 16    
17.Hodges TC, Fillinger M, Zwolak RM, et al. Longitudinal comparison of dialysis access methods: risk factors for failure. J Vasc Surg 1997;26:1009-19.  Back to cited text no. 17    

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Correspondence Address:
Kais Hasan Abd Altaee
Nephrology and Transplantation Department Baghdad Medical City, Baghdad
Iraq
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