In Reply to ‘Thrombolytic Protocol Potentially Reduces Catheter-Related Complications in Hemodialysis Patients’

Abstract

In reply to Drs Filiopoulos and Vlassopoulos,1Filiopoulos V. Vlassopoulos D. Thrombolytic protocol potentially reduces catheter-related complications in hemodialysis patients.Am J Kidney Dis. 2013; 62: 643Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar our article on vascular access usage patterns and catheter-related complications in the first year of hemodialysis therapy2Xue H. et al.Hemodialysis access usage patterns in the incident dialysis year and associated catheter-related complications.Am J Kidney Dis. 2013; 61: 123-130Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar described incident dialysis access use among 25,003 incident patients and showed that catheter use remains high at 78.5% at initiation and 69.7% at 90 days. Of all patients who initiated dialysis therapy with a catheter alone, 47.6% still had only a catheter at 1 year. Additional findings included that 3,327 (13.3%) patients had at least one positive blood culture, with risk in the tunneled catheter group being 3-fold higher compared with patients using a fistula or graft (P < 0.001 for either comparison), and that 32.5% of catheters required tissue plasminogen activator (tPA) use by a median of 41 days, with 59% requiring more than one tPA administration. Our study does not directly address any of the comments from Drs Filiopoulos and Vlassopoulos. Hence, we are not in a position to use the study to justify a comment on the effectiveness of tPA preventive use strategy as described, whether in support or against it. Although the findings from their group are interesting, it is a small uncontrolled single-center study that will require confirmation, particularly in light of the associated cost of the intervention and the serious potential complications, including the risk of local and systemic bleeding, that may not become readily apparent until a preventive protocol that uses a drug is in widespread use. Financial Disclosure: Dr Lacson is an employee of Fresenius Medical Care, North America. Dr Brunelli is an employee of Davita and has served as an advisor to Amgen, C.B. Fleet Company, and Proctor & Gamble. Dr Brunelli has received speaking honoria from Fresenius Medical Care North America and his spouse is employed by Astra Zeneca. Drs Xue and Ix declare that they have no relevant financial interests. Thrombolytic Protocol Potentially Reduces Catheter-Related Complications in Hemodialysis PatientsAmerican Journal of Kidney DiseasesVol. 62Issue 3PreviewWe read with interest the article by Xue et al1 on hemodialysis (HD) access type and catheter-related complications during the first year of dialysis. The authors reported that 32.5% of catheters, probably tunneled, required tissue plasminogen activator (tPA) use, 59% had more than one tPA administration, and 17.9% eventually were removed because of thrombosis. Catheter dysfunction and subsequent replacement are associated with high infection risk and increased financial burden. Therefore, preventive tPA use appears to be a reasonable cost-effective option. Full-Text PDF