Permanent Central Venous Catheters Research Articles

Central Venous Oxygen Saturation in Children With Cancer.

Central venous saturation (ScvO2) can guide resuscitation of children with septic shock. The normal range of ScvO2 is typically considered as 0.70-0.80, but has not been established in children with cancer. Children with cancer are particularly prone to develop sepsis due to their immunosuppressive therapy, and usually have a permanent central venous catheter, making ScvO2 readily available. We aimed to investigate normal values of ScvO2 in clinically stable children with cancer, and the association between ScvO2, hemoglobin, and lactate. We conducted a prospective clinical study at the outpatient clinic of a tertiary pediatric hematology/oncology unit. Blood samples were collected from stable children aged 0-17.9 years who were treated for cancer between January 1 and November 30, 2019, during their routine outpatient clinic visits. A total of 183 blood samples were collected from 68 patients (24 girls and 44 boys). The predicted mean level of ScvO2 with a 95% confidence interval was 0.67 (0.56-0.78). The ScvO2 value was below the expected lower normal limit of 0.70 in 126 (69%) of the samples and in 48 patients (71%) at least once. ScvO2 was significantly associated with hemoglobin (β1 = 0.012 per g/L hemoglobin, P < 0.001), but not with age, sex, underlying diagnosis, or lactate. The study revealed that a substantial portion of clinically stable childhood cancer patients exhibited ScvO2 levels below the typical reference value of 0.70, suggesting that these children may have inherently lower baseline ScvO2 levels. This should be kept in mind when evaluating children with cancer for septic shock, emphasizing the importance of tailored assessments in this population. Further understanding of baseline ScvO2 abnormalities may be helpful if ScvO2 is used to guide resuscitation.

#1762 Reduction in intradialytic glycemia and increased oxygen consumption as potential indicators of intradialytic parenchymal stress

Abstract Background and Aims Patients undergoing chronic hemodialysis (HD) face heightened all-cause and cardiovascular mortality due to various risk factors, with intradialytic stress playing a fundamental role. Recently, the assessment of intradialytic oxygen trends has emerged as a potential parameter for evaluating parenchymal stress. Specifically, an intradialytic increase in the oxygen extraction ratio (OER), derived from the ratio of peripherical oxygen saturation to central venous oxygen saturation, identifies patients at a greater risk of intradialytic events and increased clinical risk. In addition to OER, intradialytic consumption of glucose indicates higher tissue metabolic demand, likely indicative of parenchymal stress. We hypothesize that OER and intradialytic glucose consumption may be phenomena related to increased intradialytic parenchymal stress and, therefore, may be correlated. This study aimed to assess the potential correlation between intradialytic glycemia trends and oxygen extraction (OER). Method Patients in chronic HD treatment with a central venous catheter (CVC) for HD were enrolled from January 2019 to January 2020. The exclusion criteria were: ongoing acute pathology, diabetes mellitus, and undergoing hemodialysis for less than six months. OER and glycemia were measured during three consecutive HD sessions at baseline, 15, 30, 60, and 120 minutes into treatment, and post-HD. For statistical analysis, average values for each patient across the three dialysis sessions were considered. Results Twenty patients with a permanent CVC (10 males, 10 females; age 74 ± 13 years; HD vintage 46 ± 34 months) were enrolled. The pre-HD mean OER in the initial three HD sessions was 34 ± 7, increasing to 46 ± 9 post-HD, with a mean percentage delta OER of 39 ± 20%. Evaluating OER trends in the entire population revealed an increase in OER (∆OER) from the first 15 minutes of treatment (∆OER% 15’: 14 ± 7; ∆OER% 30’: 18 ± 22, p &amp;lt; 0.01). Patients' baseline glycemia was 120 ± 31 mg/dl at the start of the HD session and 111 ± 21 at the end, with a delta of −11 ± 21 mg/dl and a glucose delta percentage of 4%. Patients with higher oxygen consumption after 15 and 30 minutes of treatment experienced a greater decrease in glycemia. Specifically, ∆OER at 15’ negatively correlated with glycemia values at 15’ (r: −0.494, p &amp;lt; 0.05), 30’ (r: −0.521, p &amp;lt; 0.05), 60’ (r: −0.644, p &amp;lt; 0.01, Fig. 1), and 120’ (r: −0.714, p &amp;lt; 0.01), and post-HD (r: −0.634, p &amp;lt; 0.05). Patients were then divided based on the magnitude of mean O2 consumption measured post-HD into two groups: ΔOER ≤ mean and ΔOER &amp;gt; mean (threshold 40%). Patients with a higher ∆OER showed a more significant decrease in glycemia from the first 15 minutes of HD, confirmed at the end of HD (ΔOER ≤ 40%: Δglucose post-HD −2 ± 40; ΔOER &amp;gt; 40%: −22 ± 28, p &amp;lt; 0.05, Fig. 2). Conclusion The data confirm that oxygen extraction during hemodialysis progressively increases from the first 30 minutes of treatment. Changes in OER are associated with a reduction in glycemia, particularly patients with higher ΔOER have a more pronounced decrease in glycemia. This association between OER and glycemia supports the hypothesis that these two parameters are linked to the same pathophysiological phenomenon, such as increased intradialytic cellular metabolic activity. Studies with larger populations will help confirm this association and propose glycemia delta as an indicator of intradialytic parenchymal stress.

#2768 Evaluation of vascular access via a TRIAGE system for hemodialysis: a tool to assess clinical risk in hemodialysis patients

Abstract Background and Aims The type and efficacy of vascular access (VA) in hemodialysis (HD) play pivotal roles in determining the quality of treatment and, eventually, the clinical outcome of patients. Low dialysis quality due to suboptimal vascular access functioning is a risk factor for increased cardiovascular mortality in HD. In a prior study involving 754 patients undergoing chronic HD, we demonstrated that a VA TRIAGE system effectively identified vascular accesses at a higher risk of complications both in patients with arteriovenous fistula (AVF) and in patients with central venous catheters (CVC). The TRIAGE categorization is generated monthly through a scoring system recording several parameters of each session, like blood flow, VA pressure, end HD circuit clots, external VA examination, and KT/V. Based on threshold values, VA performance is classified as Green (G), Yellow (Y), or Red). In this study, we aimed to assess whether the TRIAGE system, by identifying poorly functioning VA, could also identify patients at a higher risk of cardiovascular events. Method In this interventional prospective, blinded multicentre study, each centre utilized the VA TRIAGE electronic spreadsheet without knowledge of the generated triage. After six months of system implementation, a two-year follow-up (01/01/2020 - 01/12/2021) was conducted to record cardiovascular events (myocardial infarction, cerebrovascular accident, peripheral vasculopathy, unstable angina, atrial fibrillation, heart failure). External reviewers assessed the records, and a minimum of three months of VA follow-up was necessary for patient enrolment. Results From 18 HD centres, 757 patients were enrolled, with an average age of 64.5 ± 15.5 years; 27% were diabetics, undergoing HD for 24.4 ± 32.4 months; 369 (48.7%) had AVF, and 388 (51.3%) had a permanent CVC. Over 11.4±5.6 months of follow-up (range 3-23) and 108, 537 HD sessions recorded in the TRIAGE system, 100 cardiovascular-related events occurred during 16.3 ± 2.2 months of follow-up (range 3-23). The VA TRIAGE was: 60% Green, 35% Yellow, and 5% Red. The Green Triage group demonstrated a lower incidence of cardiovascular events independent of VA type (25% vs. 75%; P: 0.01) and a higher duration free from cardiovascular events (AVF Green vs. AVF Yellow-Red: log-rank test: 0.04). Conclusion Our VA TRIAGE system not only identifies poorly functioning vascular accesses but also effectively assesses the clinical risk in patients undergoing HD. This outcome, in our view, is linked to the diminished quality of dialysis resulting from lower VA function in the yellow and red Triage groups compared to the green Triage group. Integrating the VA TRIAGE system with additional clinical parameters enhances its capacity to assess the clinical risk of HD patients. This approach offers a more comprehensive evaluation, potentially improving the identification of patients at higher cardiovascular risk.

Malposition of Central Venous Catheter into Coronary Sinus throughout the Persistent Left Superior Vena Cava and Other Complications Related to Catheterization.

This case concentrates on the persistent left superior vena cava (PLSVC), a rare vascular anomaly which contributes to central venous catheter (CVC) misplacement. A 72-year-old woman with renal insufficiency presented to the hospital with recurrent bleeding from her permanent CVC device placed in the right common jugular vein. An initial attempt to replace the device was unsuccessful, necessitating the placement of a secondary catheter in the left jugular vein. Shortly after the procedure, the patient developed swelling of the face and neck. Further diagnostic imaging, including a chest radiograph and computed tomography (CT), revealed CVC misplacement in the PLSVC and coronary sinus, thrombosis of the common jugular vein, and a posterior mediastinal hematoma. Conservative therapy of the mediastinal hematoma was implemented and proved effective in this case. A temporary CVC was inserted into the left femoral vein. Two months later, the catheter underwent further dysfunction and a decision was made to place a long-term permanent CVC via the right femoral vein. The patient is currently awaiting an arteriovenous fistula for dialysis use. This case emphasizes the importance of radiological techniques for CVC procedural placement, as well as the detection of congenital abnormalities. Providers regularly placing CVCs should have an in-depth knowledge of the possible complications and potential anatomical variations, especially as seen in high-risk patients.

Right-Sided Endocarditis Secondary to Aeromonas hydrophila: A Case Report

Right-sided endocarditis represents a distinct clinical condition observed in individuals with a history of parenteral drug use or those with implanted pacemakers or other intracardiac devices. Aeromonas infections, although uncommon in humans, particularly endocarditis cases, are exceedingly rare. Here, we report the case of a 72-year-old female with a medical history of arterial hypertension and chronic kidney disease undergoing hemodialysis via a tunneled permanent central venous catheter. She presented with chills and a fever of 38.3°C. Physical examination revealed a grade 3 protosystolic murmur at the tricuspid focus. Blood cultures from central and peripheral sites yielded growth of Aeromonas hydrophila. Transthoracic echocardiography demonstrated a fusiform, semi-mobile vegetation measuring 16 x 15 mm at the outlet of the superior vena cava, suggestive of endocarditis. Intravenous fluoroquinolones were initiated based on antibiogram results, leading to resolution of imaging findings after a 21-day treatment course.

Technical requirements and devices available for long-term hemodialysis in children-mind the gap!

Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.

#6282 MAKING DECISION OF VASCULAR ACCESS TYPE BASED ON UPPER ARM DOPPLER PARAMETERS AMONG INCIDENT HEMODIALYSIS PATIENTS: A SINGLE CENTER EXPERIENCE

Abstract Background and Aims Functional vascular access (VA) remains one of the most important problems related to successful hemodialysis (HD) treatments. Pivotal issue related to inadequate vascular access is decision making process of which type of VA should be created at start. Therefore, the aim of our study is to examine possible impact of Doppler examination of upper arm on decision of VA type creation. Method During 5 year period (January 2018th- December 2022th), 260 patients started hemodialysis in our department. Among them, 18 died during the first three months after HD was started, 3 were transferred to other hospitals for chronic HD program and 5 have created vascular access in other hospitals. So, we analyzed data for 234 patients (No=150, 63.6% males, mean age 62.6±13.8) which vascular access were created in our Center. We have divided them into two groups (Group A-patients with arterio-venous fistula (AVF) as first created VA and group B-patients with arterio-venous graft (AVG) or permanent central venous catheter (pCVK) as first created VA. From medical records, we have collected demographic data, type of created vascular access, Doppler parameters of upper arm and laboratory findings. Results Out of 234 patients, in Group A were167 patients (male No=109, 65.2%, mean age 61.0 years±13.8), while in group B were 67 patients(male No=40, 59.7% mean age 66.8 years±13.2). In table 1, demographic, laboratory and Doppler data is presented. We found that in Group A patients are statistically younger (61.0 years ±13.8 vs 66.8 years ±13.2, P = .004) and their vena cephalica (2.9mm± 2.5 vs 1.9mm±0.1, P = .000) and arteria radialis (2.2mm±0.4 vs 1.9mm±0.1, P = .002) are with better diameters. Also, their protein levels were statistically lower (69±9 vs 78±3, P = .036) and CRP levels higher (21.2±35.3 vs 8.1±2.1, P = .000) compared to Group B. Binary logistic regression revealed that there are no statistically significant variables that could impact decision to create AVF, but larger diameter of vena cephalica increase this decision over 13 fold (OR 13.497, CI 0.706-257.868, P = .084), and diameter of arteria radialis 17 fold (OR 17.073, CI 0.372-784-182, P = .146). Conclusion Diameteres of vena cephalica and arteria radialis could be the main variables in the planning of type of vascular access.

#5014 VALIDATION AND APPLICABILITY OF A MONITORING SYSTEM FOR VASCULAR ACCESS IN HAEMODIALYSIS: A MULTICENTRE STUDY

Abstract Background and Aims Routine systems for monitoring vascular access (VA) performance are lacking. We recently showed that with a VA triage system it is possible to improve the average value of a number of VA efficiency parameters and that the VA triage score was associated with clinical outcomes. The triage categorization is generated monthly by a scoring system which is based on a number of parameters (blood flows, VA pressure values, end HD circuit clots and a dedicated score of the external VA examination, KT/V) recorded at each session by the staff on a dedicate electronic spreadsheet. According to threshold values, triage classified each VA in Green (G), Yellow (Y) or Red (R), thus indicating the VA performance and the clinical risk of complication linked to VA. In our open label single centre study, with three years of follow-up, the average VA score improved significantly and G VA associated with lower mortality, compared to the Y and R VA. Aims: To validate the ability of the triage system to early identify VA with increased risk of complications. Methods In this interventional prospective, blinded multicentre study, each centre used the VA triage electronic spreadsheet without knowledge of the generated triage. After six months of system implementation, two years of follow-up (01/01/2020 - 01/12/2021) were planned to record VA related events. Two external reviewers evaluated the records. A minimum of three months VA follow up was necessary for patients enrolment. Results From 18 HD centres we enrolled 757 patients, aged 64,5±15,5 y.o.; 27% diabetics; HD since 24,4±32,4 months; 369 (48,7%) with arteriovenous fistula (AVF) and 388 (51,3%) with permanent central venous catheter (CVC). During 11,4±5,6 months of follow-up (range 3-23), 108537 HD sessions were recorded on the triage electronic spreadsheet, with 214 total clinical events and an event free time of 224,5 ±172 days (range 4-713). The VA related events were 150 (70,1%) during 16,3±2,2 months of follow up (range 3-23) with an event free time of 230±160 days (range 11-713). The VA Triage was: 60% Green, 35% Yellow and 5% Red. In the 369 patients with AVF the VA Triage was: 61% Green, 36% Yellow and 3% Red; The AVF Triage Green group showed: lower incidence of VA related events respect to the AVF Triage Yellow and Red group (30% vs 48%; P: 0.05); higher time-free from VA events (AVF Green vs AVF Yellow-Red: log-rank test: 0.04). Similar results were confirmed in the CVC groups: VA events incidence Triage Green 15% vs Triage Yellow-Red 40% (p: 0.001; time-free from VA events log-rank Test 0.001). Conclusion Our VA triage system identifies 40% of vascular accesses as yellow-red triage. These VA were not identified as at elevated clinical risk by the dialysis staff and only the Triage system was able to highlight them as critical. Notably the VA access with Yellow and Red Triage independently from the VA typology had an higher risk of clinical complications that according to the time survival curve could be detectable roughly 237,8 days before the event developed. The Triage system was able to identify early the VA with increased clinical risk and it may be a useful tool to prevent VA complication.

#3182 IT FOLLOWS: THE EFFECTS OF COVID ON THE INCIDENCE OF OPTIMAL RENAL REPLACEMENT THERAPY YEARS AFTER ITS ONSET

Abstract Background and Aims Patients with advanced chronic kidney disease and those on dialysis have had increased morbidity and mortality in relation to COVID infection. However, patients who did not contract the infection also suffered its effects; since the lack of face-to-face consultations and the impossibility of going to the Emergency Department during the pandemic had negative results on the care of these patients’ kidney condition. Method We present a single-center retrospective observational study of a cohort of 423 patients that were discharged from the ACKD clinic from the start of 2018 to the end of 2022 to initiate renal replacement therapy. We recorded whether the initiation had been optimal or not, defining non-optimal renal replacement therapy as patients who had: • Initiated RRT due to an acute decompensation of their underlying disease that required hospitalization. • Initiated hemodialysis through a central venous catheter instead of an arteriovenous fistula, because the access was not mature yet or otherwise unavailable. • Had to change their preferred form of renal replacement therapy because of rapid decompensation. • Chose conservative management, but died without benefiting from home medical and nursing care. We also collected their age, cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidemia, obesity and smoking), initial preferred therapy, actual RRT, reason of non-optimal therapy and whether there had been an intercurrent COVID infection at the time of initiation. Results We analyzed 423 patients that had chosen a preferred RRT (16,8% chose conservative therapy and were treated by home care services, 34% initiated hemodialysis through an AVF, 27,4% initiated dialysis through a permanent central venous catheter, 5,2% through a temporal CVC, 13,5% initiated peritoneal dialysis, 1,7% died before initiating their preferred technique and 1,4% underwent a preemptive kidney transplant). The patients that initiated hemodialysis before the pandemic started had a significantly lower risk (p 0,001) of starting RRT in a non-optimal manner (HR 0,514 [95% CI] 0,341-0,775) compared to those after the pandemic. Of the cardiovascular risk factors, only diabetes mellitus was significantly associated with non-optimal RRT (p 0,005). Patients without diabetes had significantly less risk of substandard RRT initiation (HR 0,561 [95% CI] 0,373-0,845). Patients with COVID at the time of starting renal replacement therapy had a significantly higher risk of beginning it in a non-optimal way (p 0,013). Age had no statistically significant relation to optimal RRT. The most frequent reason for non-optimal RRT was an acute decompensation that required hospitalization, which accounted for 62% of the patients. 9,6% had a catheter inserted even though they were arteriovenous fistula carriers, and 9% had to change techniques. As for the rest, they chose conservative management but died without home care or two or more reasons were named. Conclusion The incidence of COVID has decreased since the early years of the pandemic, and the effects of the virus are less lethal thanks to vaccines. However, the harmful effects of the pandemic on the care of renal patients and the evolution of their disease are still present, as it is shown by the result of our study. We should be especially mindful of patients with diabetic disease and undergoing a covid infection, because these factors may precipitate non-optimal renal replacement therapy initiation.

Oxygen Extraction and Mortality in Patients Undergoing Chronic Haemodialysis Treatment: A Multicentre Study.

Patients on haemodialysis (HD) suffer a high mortality rate linked to developing subclinical hypoxic parenchymal stress during HD sessions. The oxygen extraction ratio (OER), an estimate of the oxygen claimed by peripheral tissues, might represent a new prognostic factor in HD patients. This study evaluated whether the intradialytic change in OER (ΔOER) identified patients with higher mortality risks. We enrolled chronic HD patients with permanent central venous catheters with available central venous oxygen saturation (ScvO2) measurements; the arterial oxygen saturation was measured with peripheral oximeters (SpO2). We measured OER before and after HD at enrolment; deaths were recorded during two-years of follow-up. In 101 patients (age: 72.9 ± 13.6 years, HD vintage: 9.6 ± 16.6 years), 44 deaths were recorded during 11.6 ± 7.5 months of follow-up. Patients were divided into two groups according to a 40% ΔOER threshold (ΔOER < 40%, n = 56; ΔOER ≥ 40%, n = 45). The ΔOER ≥ 40% group showed a higher incidence of death (60% vs. 30%; p = 0.005). The survival curve (log-rank-test: p = 0.0001) and multivariate analysis (p = 0.0002) confirmed a ΔOER ≥ 40% as a mortality risk factor. This study showed the intradialytic ΔOER ≥ 40% was a mortality risk factor able to highlight critical hypoxic damage. Using a ΔOER ≥ 40% could be clinically applicable to characterise the most fragile patients.

Scheduled screening of patency of permanent central venous dialysis catheters

Background: The number of hemodialysis patients is being increased year by year throughout the world, due to the increase in the life expectancy of the population, as well as the increase in incidences of hypertension and diabetes among them, but also due to the fact that many of the patients with heart and renal failure are now being dialyzed. Hemodialysis requires vascular access. But diabetics, hypertensives, as well as the elderly patients, usually have no vessels (arteries and veins) capable enough to give a satisfactory blood flow via a fistula, so the catheter is the only choice. Objective-Design: A well-functioning catheter is a prerequisite for the quality of the clearance provided. In the present study, control of the catheter patency was performed in a monthly basis. If the blood supply remained high (at least &gt;300 ml/min) the catheter was considered to function satisfactorily. Participants-Results: The study examined the patency of permanent dialysis catheters in 34 patients (19F, 15M). The catheter survival was found to be good in all cases (100%) with a blood supply of at least &gt;300 ml/min for 17 months. Furthermore, 75% of the catheters had a good blood supply for 20 months, while 6 catheters survived with good function for 25 months and continue to operate satisfactorily even now. Conclusion: The study found out that the method of controlling the patency of permanent dialysis catheters was easy and efficient for the timely detection of those that were malfunctioning and that the results from their use were satisfactory, compared to those of other researchers in the literature.

MO792: Validation and Applicability of an Innovative Monitoring System for Vascular Access in Haemodialysis—A Multicentre Study

Abstract BACKGROUND AND AIMS Routine systems for monitoring vascular access (VA) performance are lacking. We recently showed that with a VA triage system it is possible to improve the average value of a number of HD efficiency parameters and that the triage score was associated with clinical outcomes [1]. The triage categorization is generated monthly by a scoring system which is based on a number of parameters (blood flows, VA pressure values, end HD circuit clots and a dedicated score of the external VA examination) recorded at each session by the staff and by the KT/V value recorded once every month. According to threshold values, each VA is classified as Green (G), Yellow (Y) or Red (R), thus attracting the attention of the staff. In our open-label single centre study, with 3 years of follow-up, the average VA scores improved significantly and G VA associated with lower mortality, compared to the Y and R VA. To validate our triage system with a multicentre, blinded approach in a large number of patients. The primary outcome was to evaluate if the triage identifies VA with an increased rate of complications; the secondary outcome was to verify the association of G VA score with better clinical outcomes. METHOD In this interventional prospective multicentre study, each centre used the electronic spreadsheet without knowledge of the generated score and triage. After 6 months of system implementation, 2 years of follow-up (1 January 2020–1 December 2021) were planned to record VA-related events. Two external reviewers evaluated the records. A minimum of 3 months VA follow-up was necessary for patients’ enrolment. RESULTS From 18 HD centres we enrolled 757 patients, aged 64.5 ± 15.5 years; x/y M/F; 27% diabetics; HD since 24.4 ± 32.4 months; 369 (48.7%) with arteriovenous fistula (AVF) and 388 (51.3%) with permanent central venous catheter (CVC). During 11.4 ± 5.6 months of follow-up (range 3–23), 108 537 HD sessions were recorded on the triage electronic spreadsheet, with 214 total clinical events and an event-free time of 224.5 ± 172 days (range 4–713). The VA-related events were 150 (70.1%) with an event-free time of 230 ± 160 days (range 11–713). As of today, we have the association of VA triage with VA events in a subgroup of 300 patients (66.1 ± 11.7 years; HD vintage 28 ± 18; diabetes 27.6%; 180 with AVF and 120 had CVC) who are not different from the remaining 457. In this subgroup, 54% had G VA triage, 39% Y and 7% R. In the subgroups distinguished by VA type, AVF cases (64.5 ± 12.1 years; HD since 30.3 ± 27.2; 24.4% diabetics) were triaged as G in 54%, Y in 41% and R in 5%, while CVC cases (66.5 ± 11.7 years; HD since 28.8 ± 36.5 months; 34.3% diabetics) were G in 54%, Y in 34% and R in 11%. 83 patients had VA-related events VA during 16.3 ± 2.2 months of follow-up (range 3–23), with an event-free time of 237.8 ± 195.9 days. Figure 1 shows how both AVF and CVC patients, stratified into only two triage groups (G versus Y and R together) according to their average triage, had significantly different time-free from events, which was higher in both populations (AVF P = 0.04; CVC P = 0.001) in the green triage groups. CONCLUSION Our VA triage system identifies 40% of vascular accesses as yellow-red triage, thus deserving clinical surveillance. This score has increased the rate of clinical complications which, according to the time survival curve could be detectable roughly 237.8 days before the event developed.

Interventions for treating catheter-related bloodstream infections in people receiving maintenance haemodialysis.

Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous catheter (CVC). CVC use is related to frequent complications such as venous stenosis and infection. Venous stenosis occurs mainly due to trauma caused by the entrance of the catheter into the venous lumen and repeated contact with the vein wall. A biofilm, a colony of irreversible adherent and self-sufficient micro-organisms embedded in a self-produced matrix of exopolysaccharides, is associated with the development of infections in patients with indwelling catheters.Despite its clinical relevance, the treatment of catheter-related bloodstream infections (CRBSIs) in patients receiving maintenance HD remains controversial, especially regarding catheter management. Antibiotic lock solutions may sterilise the catheter, treat the infection and prevent unnecessary catheter procedures. However, such treatment may also lead to antibiotic resistance or even clinical worsening in certain more virulent pathogens. Catheter removal and delayed replacement may remove the source of infection, improving infectious outcomes, but this approach may also increase vascular access stenosis, thrombosis or both, or even central vein access failure. Catheter guidewire exchange attempts to remove the source of infection while maintaining access to the same vein and, therefore, may improve clinical outcomes and preserve central veins for future access. To assess the benefits and harms of different interventions for CRBSI treatment in patients receiving maintenance HD through a permanent CVC, such as systemic antibiotics alone or systemic antibiotics combined with either lock solutions or catheter guidewire exchange or catheter replacement. We searched the Cochrane Kidney and Transplant Register of Studies up to 21 December 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. We included all randomised controlled trials (RCTs) and quasi-RCTs evaluating the management of CRBSI in permanent CVCs in people receiving maintenance HD. Two authors independently selected studies for inclusion, assessed their risk of bias, and performed data extraction. Results were expressed as risk ratios (RR) or hazard ratios (HR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with their 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE. We identified two RCTs and one quasi-RCT that enrolled 760 participants addressing the treatment of CRBSIs in people (children and adults) receiving maintenance HD through CVC. No two studies compared the same interventions. The quasi-RCT compared two different lock solutions (tissue plasminogen activator (TPA) and heparin) with concurrent systemic antibiotics. One RCT compared systemic antibiotics alone and in association with an ethanol lock solution, and the other compared systemic antibiotics with different catheter management strategies (guidewire exchange versus removal and replacement). The overall certainty of the evidence was downgraded due to the small number of participants, high risk of bias in many domains, especially randomisation, allocation, and other sources of bias, and missing outcome data. It is uncertain whether an ethanol lock solution used with concurrent systemic antibiotics improved CRBSI eradication compared to systemic antibiotics alone (RR 1.61, 95% CI 1.16 to 2.23) because the certainty of this evidence is very low. There were no reported differences between the effects of TPA and heparin lock solutions on cure rates (RR 0.92, 95% CI 0.74 to 1.15) or between catheter guidewire exchange versus catheter removal with delayed replacement, expressed as catheter infection-free survival (HR 0.88, 95% CI 0.43 to 1.79). To date, no results are available comparing other interventions. Outcomes such as venous stenosis and/or thrombosis, antibiotic resistance, death, and adverse events were not reported. Currently, there is no available high certainty evidence to support one treatment over another for CRBSIs. The benefit of using ethanol lock treatment in combination with systemic antibiotics compared to systemic antibiotics alone for CRBSIs in patients receiving maintenance HD remains uncertain due to the very low certainty of the evidence. Hence, further RCTs to identify the benefits and harms of CRBSI treatment options are needed. Future studies should unify CRBSI and cure definitions and improve methodological design.

Vascular access for lipid apheresis: a challenge in young children with homozygous familial hypercholesterolemia

BackgroundHomozygous familial hypercholesterolemia (hoFH) is a rare genetic disorder leading to extremely increased LDL-cholesterol (LDL-C), resulting in high cardiovascular risk in early childhood. Lipid apheresis (LA) is an effective treatment and should be started as early as possible to prevent premature cardiovascular events. As peripheral punctures in children can be challenging due to small vessels and anxiety, this study aimed to evaluate feasibility and safety of central venous catheters (CVCs) as vascular access for LA in young children with hoFH.MethodsRetrospective analysis (2016-2019) on four children with hoFH aged 3-5 years, performing weekly or biweekly LA with a CVC.ResultsLDL-C decreased by> 60%. In three children, the use of a permanent CVC for 698, 595, and 411 days, respectively, avoided difficult peripheral access, without the occurrence of occlusion or thrombosis. Unfortunately, one child had recurrent CVC-related infections and needed an arteriovenous fistula from the age of 5.Although the mean dwell time per catheter was 212 days, there were, as expected, severe side effects of early catheter infections with sepsis and accidental self-removal. Starting LA at an early age improved or stabilized carotid intima-media thickness (IMT) in three children. However, IMT did increase in one child caused by intolerance to peripheral punctures and LA interruption.ConclusionsPermanent CVCs are a viable temporary access choice for LA in young children with hoFH until peripheral venipuncture is practicable. The risk of CVC-related infections needs to be taken into account.

Fluoroscopy and CT guided translumbar tunneled dialysis catheter for hemodialysis access failure in a case of autosomal dominant polycystic kidney disease

Vascular access in hemodialysis is essential to end-stage renal disease (ESRD) patients' survival. Unfortunately, even after years of recent advances, a significant number of patients may develop multi-access failure for many reasons. In this situation, arterial-venous fistula (AVF) or catheters placement in traditional vascular sites (jugular, femoral, or subclavian) are not feasible. In this scenario, translumbar tunneled dialysis catheters (TLDCs) may be a salvage option. The use of central venous catheters (CVC) is associated with an increased incidence of venous stenosis that can progressively limit future vascular access routes. The common femoral vein can be used for temporary access in patients in whom traditional approaches for permanent central venous access may not be feasible because of either chronically occluded or not accessible vasculature; however, this location is not preferred for long-term venous access because of the high rate of catheter related blood stream infections (CRBSI). In these patients, a direct translumbar approach to the inferior vena cava is a lifesaving alternative. This approach has been described by several authors as a bail-out option. Fluoroscopy-guided access via a translumbar approach into the inferior vena cava bares the risk of hollow-organ perforation or severe bleeding from the inferior vena cava or even the aorta. To minimize the risk of complications caused by a translumbar central venous access, we hereby present a hybrid approach with CT-guided translumbar access of the inferior vena cava followed by a conventional implantation of the permanent central venous catheter. CT scan-guided access of IVC that further helps in our case as patient has large bulky kidneys secondary to autosomal dominant polycystic kidney disease.

Rates of Neutropenic Fever in Patients with Hematologic Malignant Diseases with Central Venous Access

Background: Patients who are diagnosed with hematologic malignant diseases (HMD) almost invariably receive placement of central venous catheters (CVCs), whether temporary or permanent. These catheters are used for administration of various chemotherapies, antibiotics and even nutrition. Although the patients with HMD are immunocompromised, prophylactic use of antibiotics among these patients, especially related to CVC placement, remains controversial. This retrospective analysis evaluates the rates of development of neutropenic fever in patients with HMD with CVCs receiving prophylactic antibiotics.Methods: Data were collected retrospectively in a cohort of 268 patients with HMD who received treatment at our academic institution between 2002 to 2019. Demographic and other related data was abstracted and descriptive analysis was performed using Epi-Info - 7 software.Results: Of the 268 patients with HMD, 175 patients (65.3%) received prophylactic antibiotics and among these patients, 180 (67.2%) had a permanent CVC and 109 (40.7%) had a temporary CVC. Comparatively, 93 patients (34.7%) did not receive prophylactic antibiotics and among these individuals, 64 (68.8%) had a permanent CVC and 34 (36.6%) had a temporary CVC. In patients with a permanent central line, 84.3% of patients receiving prophylactic antibiotics developed neutropenic fever while 85% of those who did not receive prophylactic antibiotic also developed neutropenic fever. Among the individuals with a temporary CVC, 79.7% of patients receiving prophylactic antibiotics developed neutropenic fever and 65.4% of patients who were not receiving prophylactic antibiotics also developed neutropenic fever. None of the differences were statistically significant (p=0.8990 and p=0.1547 respectively).Conclusion: In this cohort of HMD patients, the rate of neutropenic fever development in patients with central venous access receiving prophylactic antibiotic was not significantly different compared to the rate of neutropenic fever development in patients with central venous access who did not receive any prophylactic antibiotic. This data suggests that there does not appear to be a significant clinical utility for prophylactic antibiotics in the prevention of neutropenic fever in patients with HMD who have central venous catheters in place. Further studies analyzing the impact of prophylactic antibiotics on true infections as an etiology for neutropenic fevers in patients with HMD and central venous catheters is warranted. DisclosuresNo relevant conflicts of interest to declare.

MO821OXYGEN EXTRACTION RATIO AND MORTALITY RISK IN HAEMODIALYSIS PATIENT: A MULTICENTRE STUDY

Abstract Background and Aims Patients on haemodialysis (HD) suffer a very high rate of cardiovascular mortality with some evidence suggesting a possible association with decreasing blood oxygen saturation (SO2) during sessions. The ratio between arterial SO2 (SaO2) and central venous SO2 (ScvO2) or Oxygen Extraction Ratio (OER), which represents an estimate of the amount of oxygen claimed by peripheral tissues and of the haemodialysis related hypoxic stress, might represent a new prognostic factor. Method We evaluate the relationship between OER values and mortality risks in HD patients in a prospective multicentre observational study. We enrolled chronic HD patients with permanent central venous catheter (CVC) and no fistula, in whom ScvO2 measurement is at hand and SaO2 is available with a peripheral oxymeter. OER ([(SaO2−ScvO2)/SaO2]×100) was measured before and after HD at enrolment (HD OER sessions) in each patients, and a one-year follow-up was planned to record the number of deaths. Results In 101 patients (age 71.5 ± 14 years on dialysis for 47 ± 38 months), during 9 ± 6 months of follow up, we recorded 35 deaths. Patients were then divided into two groups, above or below the median value of pre-HD OER, which was 30%. In these groups, the average incidence of deaths was 12% (24 deaths) and 5,5% (11 deaths) respectively (p&amp;lt;0.05), with significantly different survival curves (Kaplan-Meier log rank test = 0.04, fig). No difference in mortality was evident if we divided patients according to the median intradialytic change in OER value. Conclusion Patients with pre-HD OER &amp;gt; 30% have a higher mortality risk, most probably secondary to reduced capability to respond to HD related oxygen requirements. OER is novel biomarker to identify patients at greatest clinical risk.

MO659INITIAL EXPERIENCE OF PERCUTANEOUS ARTERIOVENOUS FISTULA CREATION

Abstract Background Arteriovenous fistulas (AVFs) for hemodialysis are inconstantly used primarily due to problems with maturation and early thrombosis. An endovascular approach -without open surgery- for fistula creation offers another option for establishing a reliable vascular access. By this procedure, a arteriovenous fistula is created in the area of the cubital fossa in the deep vascular system, either between the ulnar artery and the accompanying vein or the radial artery and radial vein and uses the perforating vein at the level of the elbow to transfer blood to the superficial network of the arm. Aim To evaluate the safety, success and maturation rates of percutaneous arteriovenous fistula creation. Materials and Methods From February 2018 to June 2020 (28 months), 30 percutaneous arteriovenous fistulas (pAVF) using the WavelinQ device were created in 30 patients (male: 100%) with end stage kidney disease. Outcome measures were safety, defined as adverse events occurring within the first month of creation, success, defined as the ability to create an anastomosis between the vessels of interest and maturation rates, defined as the ability to perform at least one successful dialysis with the AVF. Secondary outcome measures included procedural complications, secondary procedures, time to cannulation, and AVF survival. Results All cases were performed as day procedures. 23 out of 30 patients (70%) were already on hemodialysis carrying a permanent central venous catheter. Main comorbidities were hypertension (21/30; 70%), diabetes (15/30; 50%) while 11/30 (30.5%) were smokers. Success was 100% (30/30). Mean follow-up was 547 days (range: 14-1071 days). In one case a pseudoaneurysm of the brachial artery was created immediately after sheath removal and in another case, an aneurysm of the AVF anastomosis was observed 17 days post-procedure and AVF was legated with a covered stent placed in the arterial part. In all, 26/30 AVFs (86.6%) were successfully cannulated. Mean time to cannulation was 61.3 days. Another one failed after maturation during the follow-up period. In total, 15 interventions were needed to achieve maturation (15/26; 0.58 procedures per AVF). 5 maintenance endovascular interventions were performed during the follow-up period (5/26; 19.2%). Mean time from cannulation to the end of follow up was 566.2 days (range: 135-1041 days). Conclusion Current analysis suggests that percutaneous AVF creation is safe, successfully performed with high maturation rates. Large scale prospective studies are needed to validate results.

Locked Away-Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis.

Reliable vascular access is necessary for effective hemodialysis. Guidelines recommend chronic hemodialysis via an arteriovenous fistula (AVF), however, in a significant number of patients, permanent central venous catheters (CVCs) are used. The use of a tunneled catheter is acceptable if the estimated dialysis time is less than a year or it is not possible to create an AVF. The main complications associated with CVC include thrombosis and catheter-related bloodstream infections (CRBSIs), which may result in loss of vascular access. The common practice is to use locking solutions to maintain catheter patency and minimize the risk of CRBSI. This paperwork summarizes information on currently available locking solutions for dialysis catheters along with their effectiveness in preventing thrombotic and infectious complications and describes methods of dealing with catheter dysfunction. The PubMed database was systematically searched for articles about locking solutions used in permanent CVCs in hemodialysis patients. Additional studies were identified by searching bibliographies and international guidelines. Articles on end-stage kidney disease patients dialyzed through a permanent CVC were included. Information from each primary study was extracted using pre-determined criteria including thrombotic and infectious complications of CVC use, focusing on permanent CVC if sufficient data were available. Of the currently available substances, it seems that citrate at a concentration of 4% has the best cost-effectiveness and safety profile, which is reflected in the international guidelines. Recent studies suggest the advantage of 2+1 protocols, i.e., taurolidine-based solutions with addition of urokinase once a week, although it needs to be confirmed by further research. Regardless of the type of locking solution, if prophylaxis with a thrombolytic agent is chosen, it should be started from the very beginning to reduce the risk of thrombotic complications. In case of CVC dysfunction, irrespective of the thrombolysis attempt, catheter replacement should be planned as soon as possible.

POS-566 CATHETER RELATED BLOODSTREAM INFECTION (CRBSI) IN A MIDDLE-EASTERN COHORT OF HEMODIALYSIS PATIENTS: AN ANALYSIS OF 5 YEARS OF FOLLOW UP DATA

Bloodstream infections (BSI) are the second commonest cause of morbidity and mortality in end stage renal failure (ESRF) patients. Dialysis catheters are believed to be the most common contributors to BSI in this cohort. Therefore, patients who are receiving hemodialysis via long term central venous catheters (CVC) are at significantly high risk of CRBSI and its associated morbidity and mortality. Although there are several studies on CRBSI from different cohorts around the world, long-term follow up data are scarce particularly from middle eastern cohorts. We aim to fill this knowledge gap as well as to develop an antibiogram and antibiotic stewardship for this unique cohort of patients. This is a single center retrospective longitudinal study of a middle eastern cohort receiving three times a week regular hemodialysis via permanent CVC in a large out-patient setting. We analyzed all the data from December 2015 to November 2020. Data on incidents of CRBSI, etiology, antimicrobial susceptibility, CRBSI risk factors, and comorbidities were collected. For the sake of our study, we defined CRBSI with the isolation of the same microorganism from the CVC and peripheral blood culture without any other apparent source. The incidence of CRBSI was expressed as incidence per 1000 catheter days. A total of 39 incidents of CRBSI were identified during these 5 years study period. Of the reported cases, 94% grew a single organism while 6% grew polymicrobial. Of the multitude of organisms isolated, 39% were gram positives while the rest were gram negatives. Staphylococcus aureus and enterococcus were predominant gram positives while pseudomonas and klebsiella were the predominant gram negatives. No case of MRSA or fungi were isolated. The distribution of organisms is illustrated in the bar chart below. Interestingly only 70% of cases presented with the typical triad of fever, rigors, and exit site exudates, while around 20% presented with only hypotension. 10% of the cases were completely asymptomatic and were only incidental findings. The incidence of CRBSI per 1000 catheter days was calculated for every month and as illustrated by the graph below, the CRBSI rates seem quite variable throughout this study period. However, interestingly, since the beginning of the COVID19 pandemic outbreak, the CRBSI rates are conspicuously low. This might be explainable by enhanced focus on hand hygiene by both the staff and the patients themselves during this pandemic. CRBSI incidences were higher among patients with longer duration of catheter use, previous bacteremia, old age, diabetes mellitus, and recent hospitalization.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The incidence of CRBSI reported from our center seems to be comparable to other international centers around the world. The causative microorganisms and their antibiotic susceptibilities also seem to be in concordance with the rest of the world despite variations in geography, climate, and ethnicity. We conclude, that irrespective of the differences in the geographical location and study cohorts, strict adherence and attention to hand hygiene and infection control practices by both the staff and the patients are the keys to keeping CRBSI low.