Trisodium citrate 4% versus heparin as a catheter lock for non-tunneled hemodialysis catheters in critically ill patients: a multicenter, randomized clinical trial

Jean‐Pierre Quenot ,Gaël Piton,Rémi Bruyère,Amélie Cransac,Agnès Soudry-Faure,Saber Davide Barbar,Jean-Michel Rebibou,A Nadji ,Gilles Blasco,Ferhat Meziani,Camille Fleck,Thomas Crépin ,Gilles Capellier,Julie Helms,Julio Badié ,Auguste Dargent,Christine Binquet,Abderrahmane Bourredjem,Chaouki Mezher,Mathieu Boulin

doi:10.1186/s13613-019-0553-4

Abstract

BackgroundNon-tunneled hemodialysis catheters are currently used for critically ill patients with acute kidney injury requiring extracorporeal renal replacement therapy. Strategies to prevent catheter dysfunction and infection with catheter locks remain controversial.MethodsIn a multicenter, randomized, controlled, double-blind trial, we compared two strategies for catheter locking of non-tunneled hemodialysis catheters, namely trisodium citrate at 4% (intervention group) versus unfractionated heparin (control group), in patients aged 18 years or older admitted to the intensive care unit and in whom a first non-tunneled hemodialysis catheter was to be inserted by the jugular or femoral vein. The primary endpoint was length of event-free survival of the first non-tunneled hemodialysis catheter. Secondary endpoints were: rate of fibrinolysis, incidence of catheter dysfunction and incidence of catheter-related bloodstream infection (CRBSI), all per 1000 catheter-days; number of hemorrhagic events requiring transfusion, length of stay in intensive care and in hospital; 28-day mortality.ResultsOverall, 396 randomized patients completed the trial: 199 in the citrate group and 197 in the heparin group. There was no significant difference in baseline characteristics between groups. The duration of event-free survival of the first non-tunneled hemodialysis catheter was not significantly different between groups: 7 days (IQR 3–10) in the citrate group and 5 days (IQR 3–11) in the heparin group (p = 0.51). Rates of catheter thrombosis, CRBSI, and adverse events were not statistically different between groups.ConclusionsIn critically ill patients, there was no significant difference in the duration of event-free survival of the first non-tunneled hemodialysis catheter between trisodium citrate 4% and heparin as a locking solution. Catheter thrombosis, catheter-related infection, and adverse events were not statistically different between the two groups.Trial registration Registered with Clinicaltrials.gov under the number NCT01962116. Registered 14 October 2013.

Highlights

Non-tunneled hemodialysis catheters are currently used for critically ill patients with acute kidney injury requiring extracorporeal renal replacement therapy
Despite progress in the management of acute kidney injury (AKI) and high-quality catheter practices, vascular access remains the weak link in the chain of renal replacement therapy (RRT) and contributes to increased morbidity in hemodialysis patients, through catheter dysfunction and infection [1, 2]
Heparin locks are considered the reference, but the use of heparin is associated with a number of complications, including inadvertent systemic administration potentially leading to coagulopathy and bleeding, heparin-induced thrombocytopenia [3], and allergic reactions [4], rendering heparin difficult to handle in the intensive care unit (ICU)

Summary

Introduction

Non-tunneled hemodialysis catheters are currently used for critically ill patients with acute kidney injury requiring extracorporeal renal replacement therapy. Strategies to prevent catheter dysfunction and infection with catheter locks remain controversial. Non-tunneled hemodialysis catheters are currently the preferred vascular access method for critically ill patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT). Despite progress in the management of AKI and high-quality catheter practices, vascular access remains the weak link in the chain of RRT and contributes to increased morbidity in hemodialysis patients, through catheter dysfunction (stenosis and/or thrombosis) and infection [1, 2]. It is accepted practice to lock the lumen of nontunneled hemodialysis catheters with an anticoagulant solution to prevent thrombosis, maintain catheter patency, and avoid infection between dialysis sessions. A randomized, double-blind, placebo-controlled trial comparing ethanol to saline solution failed to find a decrease in the frequency of infection of dialysis catheters in ICU patients [8]

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Results

Conclusion