| Abstract|| |
Hemodialysis (HD) catheters are commonly used as temporary vascular access in patients with kidney failure who require immediate HD. The use of these catheters is limited by complications such as infections, thrombosis resulting in poor blood flow. We studied the complications and outcomes of nontunneled catheters used for vascular access in our dialysis unit. The records of all patients, with renal failure who were dialyzed over a two-year period and had a double lumen nontunneled catheter inserted, were retrieved. Catheter insertion was carried out under ultrasound guidance using the modified Seldinger technique. The demographic data of patients, etiology of chronic kidney disease, and complications and outcomes of these catheters were noted. Fifty-four patients with mean age 43.7 ± 15.8 years had 69 catheters inserted for a cumulative total of 4047 catheter-days. The mean catheter patency was 36.4 ± 37.2 days (range: 1-173 days). Thrombosis occluding the catheters was the most common complication and occurred in 58% of catheters leading to catheter malfunction, followed by infections in18.8% of catheters. During follow-up, 30 (43.5%) catheters were removed, 14 (20.3%) due to catheter malfunction, eight (11.6%) due to infection, five (7.2%) elective removal, and three (4.3%) due to damage. Thrombotic occlusion of catheters was a major limiting factor to the survival of HD catheters. Improvement in catheter patency can be achieved with more potent lock solutions.
|How to cite this article:|
Amira CO, Bello BT, Braimoh RW. A study of outcome and complications associated with temporary hemodialysis catheters in a Nigerian dialysis unit. Saudi J Kidney Dis Transpl 2016;27:569-75
|How to cite this URL:|
Amira CO, Bello BT, Braimoh RW. A study of outcome and complications associated with temporary hemodialysis catheters in a Nigerian dialysis unit. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Dec 2];27:569-75. Available from: https://www.sjkdt.org/text.asp?2016/27/3/569/182401
| Introduction|| |
The ideal long-term vascular access for hemo- dialysis (HD) is a native arteriovenous fistula (AVF).,Temporary vascular access can be established using HD catheters if urgent dialysis is required in acute kidney injury (AKI)or in patients with end-stage renal disease (ESRD) who require HD before their AVF is esta- blished or have experienced failure of their AVF or as a bridge to transplantation or peri- toneal dialysis.Nontunneled catheters are indicated for short-term HD access and accor- ding to current Kidney Disease Outcomes Quality Initiative (K/DOQI) Guidelines their continuous use should be limited to <3 weeks.When it is anticipated that a catheter will be needed for more than three weeks then a tunneled cuffed catheter is preferred.,HD catheter use is however associated with lower patency rates and higher rates of infections, hospitalization, and mortality compared with AVF.,,,,In addition, these temporary catheters require regular flushing with heparin to pre- vent clotting. Despite these measures, clotting and consequent diminished flows are quite common.Catheters which are left in place too long, carry a significant risk of infection. Nontunneled catheters are often uncomfortable and unattractive to the patient and there is risk of central venous stenosis.
Despite these shortcomings, the use of non- tunneled catheters as vascular access for HD remains substantial.In Nigeria where most patients present late,,there has been a recent shift away from repeated femoral vein cannu- lation,,towards insertion of nontunneled HD catheters into the internal jugular or subclavian veinswith these catheters sometimes left in situ for several weeks.
Given this recent increase in the use of temporary HD catheters, we therefore carried out this study to evaluate all temporary HD catheters inserted in our dialysis unit over a two year period with a focus on the compli- cations, patency rates, and outcomes.
| Subjects and Methods|| |
We retrospectively reviewed the data on all HD catheters inserted at the dialysis unit of the Lagos University Teaching Hospital (LUTH), a Tertiary Hospital located in Lagos, South- west Nigeria from January 2010 to December 2011. Data on all inserted catheters and catheter-related complications, as well as pa- tency, were extracted from the patient's dialysis unit records. These, as well as the baseline characteristics and demographic data of the patients, were retrieved.
Catheter insertion procedure
Double lumen nontunneled HD catheters (Medcomp Soft-Line, Harleysville PA1) were inserted under strict asepsis and were sutured to the skin. Catheters were inserted under ultra-sound guidance using the modified Seldinger techniqueeither in the dialysis unit or the Radiology Department of the hospital by the Nephrologist. The preferred site of insertion was the right internal jugular vein, but occa- sionally in the right subclavian.The position of the catheter tip was verified radiologically immediately after insertion. Patients with ca- theters inserted into the femoral vein were excluded from the analysis.
Catheter care protocol
Catheters were used exclusively for HD and handled by only dialysis nurses wearing sterile gloves and face masks. Before each dialysis session, the catheter hubs were cleaned with 2% chlorhexidine solution, the anticoagulant lock was withdrawn, and then the lumen was "flushed" with saline before being connected to the bloodlines. At the end of each dialysis session, all catheters were flushed with saline and were locked with unfractionated heparin (1000 U/mL) with a volume equivalent to the internal volume of the lumen noted on the catheter. A dry dressing was applied on the catheter and inspected or changed during each dialysis treatment. Patients who dialyzed less frequently than twice a week were required to visit the hospital on at least one other day to have the catheter "flushed" with saline and "locked" with heparin to prevent thrombosis as well as have the dressing changed. When catheters were occluded with a thrombus, an attempt was made to reopen the catheter using heparin solution 5000 U/mL instilled into the lumen for one to 2 h as thrombolytic agents were not available in our environment. In general, when blood flow rate (Qb) improved but 250 mL/min was not achieved, the proce- dure could be repeated; otherwise, the catheter was removed or exchanged over a guide wire.
Catheters were removed when:
- They were no longer needed (recovery of kidney function, AVF maturation, and renal transplantation)
- Significant complications developed (ca- theter dysfunction, exit site infection, and catheter-related bacteremia (CRB) that was unresponsive to a combination of systemic and intra-catheter antibiotics, and catheter damage).
- Catheter mechanical dysfunction was de- fined as inability to achieve blood flow rate of >250 mL/min or high blood pump pressures despite attempts to improve flow such as patient repositioning or reversal of catheter lumen
- Definite CRB was defined as fever with temperature >38°C with isolation of iden- tical micro-organism from cultures of blood and catheter tip and no other obvious focus of infection
- Possible CRB was defined as fever with temperature >38°C and no other obvious focus of infection and where the microbio- logical criteria were insufficient to make a diagnosis of definite CRB
- Exit site infection was defined as the deve- lopment of cellulitis or purulent discharge at the site of catheter insertion.
| Statistical analysis|| |
Data analysis was performed with Epi Info statistical software, version 6 (Centers for Disease Control and prevention USA). Descrip- tive analysis was carried out; data were repor- ted as mean ± standard deviation and propor- tions. Each individual catheter episode was analyzed separately in those patients who had more than one catheter inserted during the period of the study. Catheters exchanged over a guide wire were also treated as a single catheter episode. The cumulative duration of catheter usage was the sum of duration for each catheter usage in those patients who had more than one catheter inserted.
| Results|| |
Fifty-four (11.7%) patients out of 461 patients who were dialyzed in the unit during the period under review had nontunneled HD catheters inserted. Of these, 47 (87%) had CKD, six (11.1%) had AKI, and one patient (1.9%) had a biventricular failure and needed isolated ultrafiltration. Thirty-one (57.4%) were females and the mean age of the study population was 43.7 ± 15.8 years (range: 8-79 years). The mean duration on dialysis was 5.66
± 6.16 months. Majority of our patients (50%) dialyzed once a week, 25.9% dialyzed once in two weeks while 1.9% dialyzed thrice weekly. [Figure 1] shows the frequency of dialysis among study subjects. The major indication for insertion of HD catheter was vascular access for HD following difficulty accessing the femoral veins and as a bridge until a more definitive form of vascular access could be created.
A total of 69 catheters were inserted, 97.1% in the right internal jugular, and 2.9% in the right subclavian vein. Two patients had four catheters inserted; one patient had three while seven patients had two catheters inserted. All patients with more than one catheter inserted had ESRD and were on dialysis for a longer period. The catheters remained in situ for a cumulative total of 4047 catheter-days. The mean catheter patency was 36.4 ± 37.2 days (range: 1-173 days). [Table 1] shows the clin- ical characteristics of the study subjects.
The most commonly reported complication was catheter thrombosis occurring in 40 (58%) catheters leading to catheter dysfunction with resultant poor blood flow. Three patients reported mild bleeding at the catheter insertion site which was arrested by compression. There were no cases of pneumothorax, hemothorax, or other major insertion-related complications.
Thirteen (18.8%) catheters in 11 patients (20.4%) were complicated by fever in the absence of alternative sources of infection and were considered to have possible CRB. A combination of parenteral and intra catheter antibiotics was successful in controlling the infection in five patients; however, eight ca- theters had to be removed to control infection and catheter tips were cultured. The average time to infection was 77.9 ± 66.7 days (range was 9-225 days). Culture yielded Staphylolococcus aureus in four, Pseudomonas aerogenosa in one, while in the other three catheters, no microbial growth was detected. The criteria for CRS were met in only one patient in whom both the blood and catheter tip yielded a growth of P. aerogenosa. Three patients died from catheter-related sepsis.
During the follow-up, 30 (43.5%) catheters were removed giving a catheter removal rate of 7.4/1000 catheter-days. Fourteen (20.3%) catheters were removed due to mechanical dysfunction, eight (11.6%) due to infection, three (4.3%) due to physical damage. Five catheters (7.2%) were removed electively (2- AVF maturation, 1-kidney transplant, and 2- patients with AKI who recovered kidney function). Three patients were transferred to another facility, seven died with a functioning catheter, and 32 were lost to follow-up and presumed to have died at home. Only three patients still had functioning catheters at the end of the review. [Table 2] shows a comparison of our findings with those of similar studies.
| Discussion|| |
In this study, the major indication for insertion of temporary HD catheters was vascular access for HD in patients with CKD. Majority of our patients start HD without any form of vascular access thus leading to high dependence on HD catheters for vascular access. This finding of a high dependence on HD catheters for initial vascular access, though at variance with current guidelines has been reported from several centers including ours.,,,,Little et alreported that 50-60% of patients in their study depended on tunneled catheters for access, while Altaee et alreported that 42% of those who had temporary HD catheters inserted had CKD. This is in contrast to reports from Europe where majority are dialyzed through AVFs.Reasons for the high dependence on catheters include late referral, late presentation, delay in construction of long-term access due to dearth of experts, and high cost of surgery. Efforts should be geared toward improving on this practice through timely construction of AVF at least within six months of anticipated need for dialysis as recommended by K/DOQI.This can be achieved through the setting up of predialysis clinics where CKD patients can be managed and prepared for subsequent renal replacement therapy as well as training in vascular access surgery.
The most common complication encountered in this study was catheter dysfunction due to thrombosis with resultant poor blood flow rates. Catheter dysfunction affects the adequacy of dialysis delivered and this has been reported in the literature.,Thrombosis in the catheter lumen is usually due to inadequate heparini- zation. The incidence of catheter dysfunction in this study is significantly higher than that reported in the previous studies.,,One possible explanation for this unusually high incidence of catheter dysfunction could be as a result of the lower concentration of heparin solution used as a locking agent as well as the fact that most of our patients were dialyzed infrequently. We had previously reported that majority of patients on maintenance dialysis at our facility were having dialysis less frequently than once weekly.Maintaining patency requires the use of heparin locks and several attempts have been made to reduce thrombosis by using different agents like citrate and thrombolytic agents. Thrombolytic agents have been used as locking agents and are shown to be effective in reducing catheter dysfunction in some small studies.Citrate locks have anti- thrombotic and potential anti-bacterial pro- perties, but the problem is determining the optimal concentration that will deliver both effects. Higher concentrations are needed for antimicrobial activity and there are safety concerns over using higher concentrations. The American Society of Diagnostic and Interventional Nephrology Clinical Practice Committee recommend using 4% trisodium citrate to maintain patency for tunneled ca- theters.However, citrate locks are not readily available in Nigeria at this time. Given the high rates of catheter dysfunction, there is a need to review the concentration of heparin used to lock the catheters. We therefore re- commend as part of catheter care the use of higher concentration of heparin such as 2500 U/mL and also thrice weekly flushing of the catheters in our center irrespective of the frequency of dialysis. Not using these higher strengths of heparin is the fear of unintentional systemic anticoagulation but this can be avoided if exact fill volumes are used. These recommendations are subject to further re- search to clearly ascertain the benefits of such practices. Despite the high rate of catheter dysfunction documented, the mean catheter patency in our study was similar to that re- ported by Altaee et al.,
The most common indication for removal of catheter in our study was catheter malfunction (13%). This is in contrast to most studies in the literature in which elective removal accounted for the major reason for remo- val.,,Very few catheters were electively removed in our series. This is due in part to the low rate of migration to AVF access. The low rates of migration to AVF access noted in this study are due to several factors including financial constraints because patients have to pay out of pocket for renal care and fear of disfigurement after the AVF is created. More- over, our patients tend to stay on dialysis for short periods before they are either lost to follow-up or die from complications of ESRD as a result of infrequent dialysis. In this series, 39 (72%) of the patients were either lost to follow-up or were known to have died during the period under review. There is a need to encourage the creation of AVF as permanent vascular accesses so as to improve quality of HD therapy delivery as studies have shown that individuals with AVF experience fewer complications compared with those who use catheters.
The rate of catheter-related infections in our series is lower than reports from most series. This may appear quite surprising at first glance, especially considering the duration for which the catheters were in place and the fact that the rates of infections have been shown to be related to the duration for which the ca- theters were in situ. However, when one consi- ders that majority of the patients were lost to follow-up and presumed to have died without documentation of the cause of death, then, the low rate of infectious complications found in this study may likely be an under-representation. Of the 13 catheters that were suspected to be complicated by CRB, bacteriologic confir- mation was obtained in five (38%) a finding that is likely to be due to the fact that anti- biotic therapy was instituted before samples for culture were obtained. The most common organism isolated was S. aureus consistent with reports from other studies.,In the 17 cases of proven CRB in the study by Altaee et al, all the organisms isolated were Staphylo- coccus species, (S. aureus in 6, methicillin resistant S. aureus in 4, and coagulase negative Staphylococcus in 7).
One major limitation of this study was the high dropout rate as most of the patients were lost to follow-up after only short periods on dialysis because of financial constraints so it was not possible to determine what could have happened if they had remained until the end of the study.
| Conclusion|| |
Ultrasound-guided temporary HD catheters insertion is safe and infrequently associated with major complications. However, thrombotic occlusion of catheters was a major limiting factor to catheter survival. Efforts should be geared toward improving catheter patency by the use of other locking solutions as well as timely creation of AVF as long-term vascular access for HD so as to minimize dependence on temporary HD catheters.
Conflict of interest: None.
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Christiana Oluwatoyin Amira
Department of Medicine, College of Medicine, University of Lagos, PMB 12003, Idi-Araba, Lagos
[Table 1], [Table 2]