Abstract
BackroundThe study aim was to establish if substitution of citrate with rt-PA for catheter lock once weekly can reduce the incidence of catheter-related blood stream infections (CR-BSI) or improve patency of tunneled haemodialysis catheters.MethodsAll incident patients undergoing insertion of a tunneled haemodialysis catheter were screened and included except those suffering infection or using oral anticoagulation. Study participants were randomized into two arms according to the solution applied as catheter lock: receiving either trisodium citrate (Citra-LockTM 4%) only or rt-PA (Actilyse® 1 mg/ml) on the middle session each week with citrate used on the first and third sessions. The incidence of CR-BSI (confirmed by positive blood culture), catheter non-function (complete obstruction), and malfunction (blood flow < 250 ml/min) was recorded. Statistical significance was tested with ANOVA, post hoc analysis was performed by means of multiple linear regression.ResultsTotally, 18 patients were included and followed during 655 haemodialysis sessions. No episode of CR-BSI was detected while 6 catheter non-functions (0.9% sessions) and 101 malfunctions (15.4% sessions) were recorded. The incidence of both events was equal between the study arms: 4 non-functions and 55 malfunctions in the rt-PA arm and 2 non-functions and 46 malfunctions in the citrate arm (p = 0.47 and p = 0.24, respectively). Additionally, the mean blood flow achieved did not differ significantly between the arms: 326 ± 1,8 and 326 ± 1,9 ml/min (p = 0.95) in rt-PA and citrate arms, respectively. Post hoc analysis identified time elapsed since previous session (β = 0.12, p = 0.005) and malfunction on previous session (β = 0.25, p < 0.001) as significant factors affecting the occurrence of malfunction. By contrast, the study arm, rt-PA application on previous session, and catheter vintage did not enter the model.ConclusionSubstitution of citrate with rt-PA for catheter lock does not reduce the incidence of catheter malfunction neither does it affect the blood flow achieved during haemodialysis. Catheter patency is related rather to the time interval between sessions and to previous malfunction (thus probably reflecting undefined individual factors). The incidence of CR-BSI within pre-selected haemodialysis population is sporadic (less than 1 per 4.3 patient years in our sample).Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12612000152820. Retrospectively registered 03/02/2012.
Highlights
A number of guidelines and initiatives strongly recommend native arteriovenous fistulas (AVF) and discourage the use of catheters for chronic dialysis treatment [1,2,3]
Substitution of citrate with recombinant tissue plasminogen activator (rt-PA) for catheter lock does not reduce the incidence of catheter malfunction neither does it affect the blood flow achieved during haemodialysis
Study participants were randomised by block method into two groups (1:1, four patients in one block) according to the solution applied as a catheter lock: 1) receiving either trisodium citrate (Citra-LockTM 4%) only or 2) rt-PA (Actilyse® 1 mg/ml, volume adjusted with saline to match the lumen) in the middle session each week with citrate used in the first and third sessions
Summary
A number of guidelines and initiatives strongly recommend native arteriovenous fistulas (AVF) and discourage the use of catheters for chronic dialysis treatment [1,2,3]. This fistula first policy is based on evidence from large observational studies showing that the use of AVF is associated with the lowest (and catheters with the highest) risk of death from infection and cardiovascular disease [4, 5]. Up to 60% of AVFs fail immediately after surgery or fail to mature [8, 9]. Noordzij et al found that female patients and those > 80 years were least likely to start HD with an AVF, according to European renal registries between 2005 and 2009 [6]
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