Assessing Mechanical Catheter Dysfunction in Peritoneal Dialysis Patients: A Case Control, Proof-of-Concept Study

New guidelines on evaluation of peritoneal membrane function recommend ruling out catheter dysfunction when evaluating patients with low ultrafiltration capacity. We introduce the use of a combination of parameters obtained from daily measurements of the cycler software for predicting catheter dysfunction in automated peritoneal dialysis patients. Out of 117 patients treated between 2015 and 2021, all patients with verified catheter dysfunction (n=14) were identified and compared to controls (n=19). We retrieved cycler data for seven days each and tested parameters predictive capability of catheter dysfunction. Total number of alarms/week >7 as single predictive parameter of catheter dislocation identified 85.7% (sensitivity) of patients with dislocated catheter and 31.6% (1-specificity) of control patients. A combination of parameters (number of alarms/week >7, drain time >22 min, ultrafiltration of last fill <150 mL) where at least two of three parameters appeared identified the same proportion of patients with catheter dislocation, but was more accurate in identifying controls (21% false positive). An easily applicable combination of daily cycler readout parameters, also available in remote monitoring platforms can be used as predictor of inadequate catheter function during routine follow-up with potential for earlier diagnosis of this frequent complication in the future.

A pig model of tunneled dialysis catheter (TDC) infection and dysfunction: Opportunities for therapeutic innovation

Background: Although tunneled dialysis catheters (TDC) are far from ideal, they still represent the main form of vascular access for most patients beginning dialysis. Catheters are easy to place and allow patients instant access to dialysis, but regardless of these benefits, catheters are associated with a high incidence of significant complications like bloodstream infections, central venous stenosis, thrombosis, and dysfunction. In the present study, we aim to describe and characterize a swine model of catheter dysfunction and bloodstream infection, that recreates the clinical scenario, to help to serve as a platform to develop therapeutic innovations for this important clinical problem. Methods: Six Yorkshire cross pigs were used in this study. Non-coated commercial catheters were implanted in the external jugular recreating the main features of common clinical practice. Catheters were aseptically accessed twice a week for a mock dialysis procedure (flushing in and out) to assess for and identify catheter dysfunction. Animals were monitored daily for infections; once detected, blood samples were collected for bacterial culture and antibiograms. Study animals were euthanized when nonresponsive to treatment. Tissue samples were collected in a standardized fashion for macroscopic inspection and histological analysis. Results: The data analysis revealed an early onset of infection with a median time to infection of 9 days, 40% of the isolates were polymicrobial, and the average time to euthanasia was 20.16 ± 7.3 days. Median time to catheter dysfunction onset was 6 days post-implantation. Postmortem dissection revealed external fibrin sheath and internal thrombosis as the main causes of catheter dysfunction. There was also evidence of central venous stenosis with positive cells for αSMA, CD68, Ki67, Smoothelin, and Vimentin within the venous neointima. Conclusions: The described model represents a reliable and reproducible large animal model of catheter dysfunction and bloodstream infection, which recreates all the main complications of TDC’s and so could be used as a validated large animal model to develop new therapies for TDC related infection, thrombosis/dysfunction and central venous stenosis.

A 2% taurolidine catheter lock solution prevents catheter-related bloodstream infection (CRBSI) and catheter dysfunction in hemodialysis patients

HIGHLIGHTS 2% taurolidine catheter lock solution without additives is safe and efficient. CRBSI and dysfunction rates compare favorably against other studies in hemodialysis Background: In hemodialysis patients, catheter-related bloodstream infection (CRBSI) and catheter dysfunction are common and cause significant morbidity, mortality, and costs. Catheter lock solutions reduce CRBSI and catheter dysfunction rates, but solutions containing heparin, citrate, or antibiotics are associated with adverse effects. Due to its antimicrobial and antithrombotic properties and benign safety profile, taurolidine is suitable for use in catheter lock solutions. In this study the effectiveness and safety of a catheter lock solution containing 2% taurolidine without citrate or heparin (TauroSept®, Geistlich Pharma AG, Wolhusen, Switzerland) in hemodialysis patients were investigated for the first time. Methods: Data from 21 patients receiving chronic hemodialysis via tunneled central venous catheters with 2% taurolidine solution as a catheter lock were analyzed in a single-center retrospective study and compared with the existing literature in a review. The primary endpoint was CRBSI rate. Secondary endpoints included catheter dysfunction, treatment, and costs; catheter technical problems, resolution, and costs; and adverse events. Data were compared to outcomes with standard lock solutions in the literature. Results: No CRBSIs occurred during the observation period of 5,639 catheter days. The catheter dysfunction rate was 0.71 per 1,000 catheter days, and the catheter dysfunction treatment costs were CHF (Swiss Franc) 543 per patient. No technical problems or adverse events related to the use of 2% taurolidine-containing catheter lock solution were observed. These results compare favorably with other catheter lock solutions. Conclusions: A solution containing 2% taurolidine seems suitable as a hemodialysis catheter lock. In a Swiss cohort, it prevented CRBSI, limited catheter dysfunction, and was cost-efficient.

CLINICAL EVALUATION OF TENCKHOFF CATHETER INSERTION IN PAEDIATRIC PERITONEAL DIALYSIS : A SINGLE CENTER STUDY

Objective: This study aimed to evaluate the clinical outcome of Tenckhoff catheter insertion at Sardjito General Hospital for pediatric renal failure. Material & Methods: Data were collected from January 2014 to December 2018 at Sardjito General Hospital. All patient records were collected retrospectively such as patient characteristics, underlying diseases of kidney failure, congenital abnormalities, surgical technique, complications that occur after Tenckhoff catheter insertion. Results: 45 patients meet the inclusion criteria. A total of 7 patients with acute kidney failure (15.5%) and 38 patients with chronic kidney failure (84.5%). Glomerulonephritis is the most common cause of kidney failure (21 patients, 46.7%). The insertion technique used was open surgery in 34 patients (76%) and laparoscopic insertion in 11 patients (24%). Complications reported were catheter dysfunction, leakage of dialysate, surgical site infection, and peritonitis. Conclusion: Tenckhoff catheter insertion for peritoneal dialysis (PD) in pediatric patients with acute and chronic renal failure performed in our center is effective and safe. The most common cause of renal failure in pediatric is glomerulonephritis. Open surgery and laparoscopic insertion of Tenckhoff catheter both have a low complication rate. Catheter dysfunction due to mechanical catheter obstruction is one of the main problems in the placement of Tenckhoff catheter.

Comparison of ethanol lock and heparin lock solution as prevention of catheter-related bloodstream infection in hemodialysis patients: systematic review and meta-analysis of randomized controlled trials

Introduction: Catheter-related bloodstream infection (CRBSI) is a common complication of catheter use for vascular access in hemodialysis patients and a major cause of morbidity and mortality. Preventive measures, including antibiotic lock, are inadequate due to the risk of resistance and insufficient effect against bacterial biofilm. Ethanol, an antimicrobial substance, is a potential prophylactic lock-in preventing CRBSI. This study aims to assess ethanol lock's effectiveness in preventing CRBSI in hemodialysis patients with a catheter as vascular access and its impact on catheter dysfunction. Methods: Researchers systematically searched online databases including Pubmed, Cochrane Library, and Science Direct for relevant randomized controlled trials (RCTs) published within 2011 until 2020. Relevant data were pooled in PICOs (Population, Intervention, Control, Outcomes) format and analyzed with Review Manager (version 5.3.5, Cochrane Collaboration, Denmark). Results: Seven RCTs involving 453 patients were assessed. The primary outcome indicates that prophylactic ethanol lock significantly reduces the incidence of CRBSI compared to that of heparin lock (RR=0.32, 95% CI 0.12-0.83, p=0.02, heterogeneity I2=68%). The secondary outcome suggests no significant difference in the incidence of catheter dysfunction in ethanol lock and heparin lock (RR=0.75, 95% CI 0.23-2.40, p=0.63, heterogeneity I2=68%). Conclusion: Ethanol is a potential prophylactic lock agent in preventing CRBSI in hemodialysis patients with catheter access. Further research is needed to synchronize the procedural use of ethanol lock and evaluate its long-term effect.

Prevention of tunneled cuffed catheter dysfunction with prophylactic use of a taurolidine urokinase lock: A randomized double-blind trial

Background The efficacy and cost-effectiveness of prophylactic thrombolytic locks in hemodialysis patients at high-risk of thrombotic dialysis catheter dysfunction is uncertain. We investigated this question in a double-blinded randomized controlled study. Methods Prevalent hemodialysis patients from 8 Belgian hemodialysis units, with ≥2 separate episodes of thrombotic dysfunction of their tunneled cuffed catheter during the 6 months before inclusion, were randomized to either: taurolidine heparin locks thrice weekly (control arm) or the same locks twice a week combined with taurolidine urokinase locks once a week before the longest interval without HD (TaurolockU arm). The primary efficacy outcome was the incidence rate of catheter thrombotic dysfunction requiring thrombolytic locks to restore function. Results 68 hemodialysis patients (32 controls, 36 urokinase) were followed during 9875 catheter days between May 2015 and June 2017. Incidence rate of thrombotic catheter dysfunction was 4.8 in TaurolockU vs 12.1/1000 catheter days in control group (rate ratio 0.39; 95%CI 0.23–0.64). 15/36 (42%) catheters in the treatment group required at least one therapeutic urokinase lock vs 23/32 (72%) in the control group (P = 0.012). The two groups did not differ significantly in catheter-related bloodstream infection and combined cost of prophylactic and therapeutic catheter locks. The TaurolockU group had a numerically higher number of episodes of refractory thrombosis. Conclusions Prophylactic use of urokinase locks is highly effective in reducing the number of thrombotic catheter dysfunctions in catheters with a history of recurring dysfunction. Prophylactic use of urokinase locks did not reduce the overall costs associated with catheter locks and was associated with a numerically higher number of episodes of refractory thrombosis. Trial registration ClinicalTrials.gov Identifier: NCT02036255.

Peritoneal dialysis catheter dysfunction due to fibrin clots following treatment with tranexamic acid: a clinical case

Chronic kidney disease patients experience not only more frequent arterial and venous thrombosis but also hemorrhagic episodes. Tranexamic acid is an anti-fibrinolytic molecule that inhibits plasmin activation. It is used in hemorrhage cases (post-traumatic, gynecologic, or gastrointestinal bleeding). We report on an original case of tranexamic acid (Exacyl®) use in a peritoneal dialysis patient for gastrointestinal bleeding of unknown origin. The use of tranexamic acid led to the Tenckhoff catheter dysfunction because of fibrin clots in the dialysate. The emergence of fibrin clots a few days after the start of tranexamic acid treatment, which never occurred again after the end of the treatment, and the anti-fibrinolytic function of tranexamic acid favors this treatment’s role in fibrin clot occurrence.

Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial

Background Vascular access for renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. However, recent prospective observational data on RRT catheters use are scarce. We aimed to assess the site of RRT catheter, the reasons for catheter replacement, and the complications according to site in a large population of critically ill patients with acute kidney injury. Patients and methods We performed an ancillary study of the AKIKI study, a pragmatic randomized controlled trial, in which patients with severe acute kidney injury (KDIGO 3 classification) with invasive mechanical ventilation, catecholamine infusion or both were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected. Results Among the 619 patients included in AKIKI, 462 received RRT and 459 were finally included, with 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular (n = 256, 43%) and subclavian (n = 23, 4%). In multivariate analysis, continuous RRT modality was significantly associated with femoral site (OR = 2.33 (95% CI (1.34–4.07), p = 0.003) and higher weight with jugular site [88.9 vs 83.2 kg, OR = 0.99 (95% CI 0.98–1.00), p = 0.03]. Investigator site was also significantly associated with the choice of insertion site (p = 0.03). Cumulative incidence of catheter replacement did not differ between jugular and femoral site [sHR 0.90 (95% CI 0.64—1.25), p = 0.67]. Catheter dysfunction was the main reason for replacement (n = 47), followed by suspected infection (n = 29) which was actually seldom proven (n = 4). No mechanical complication (pneumothorax or hemothorax) occurred. Conclusion Femoral site was preferentially used in this prospective study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits, weight, RRT modality. A high incidence of catheter infection suspicion led to undue replacement.