Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Abstract

Arteriovenous fistulas (AVF) are the most preferred and promoted form of dialysis access due to their lowest complication rates. However, the changing demographic profile of end- stage renal disease (ESRD) with an increasing elderly and diabetic population having relatively poor vasculature, relative lack of prudent pre-ESRD planning for AV fistula creation, late referrals, and comparatively lower fistula maturation rates, are essentially the factors accountable for our continued dependence upon central venous catheters (CVCs) [1-3]. Moreover, CVCs remain the only means to provide instant access to the circulation during emergency situations arising from the unpredictable course of chronic kidney disease. Virchow's described three broad categories of factors that contribute to thrombus formation -hypercoagulability, stasis and vascular endothelial injury. The placement of this relatively large foreign body traumatizes the host vessel and significantly alters hemodynamics fulfilling Virchow’s triad for thrombus formation and provides a nidus for bacterial entry into the circulation. However, catheter malfunction limits the life span of CVCs. Inadequate blood flow and catheter-related bloodstream infections (CRBSI) are common causes of recurrent use of thrombolytic therapy, antibiotics and often result in catheter removal. Generally, standard heparin (5000 U/ mL) is used to lock the CVCs to maintain catheter patency during the interdialytic period. Locking with heparin however, does not prevent bacterial colonization and subsequent development of CRBSI. Moreover, in vitro studies have shown that heparin may induce biofilm formation [4]. Replacing heparin with recombinant tissue plasminogen activator (rt-PA) once a week, as a dialysis catheter locking solution significantly reduced the incidence of catheter malfunction and CRBSI in a well conducted multicenter, double-blind, randomized controlled trial from Canada by Hemmelgarn and colleagues [5]. The authors were able to decrease the rates of catheter malfunction by 50% and