Use Of Hemodialysis Catheters Research Articles

Evaluating and treating venous outflow stenoses is necessary for the successful open surgical treatment of arteriovenous fistula aneurysms

Arteriovenous fistula (AVF) aneurysms (AVFAs) can lead to skin erosion, bleeding, difficult access while on hemodialysis, and poor cosmetic appearance. We reviewed our experience in treating patients with aneurysmal dilatation of their AVF. We reviewed clinical data of 48 patients (37 men; overall mean age, 55 years; range, 28-85 years) with an AVFA who underwent treatment during a 30-month period. Relevant clinical variables and treatment outcomes were analyzed. All patients underwent a fistulogram, and 90% required percutaneous angioplasty to improve outflow. Fifty-six percent of patients had one stenotic outflow lesion, and 44% had at least two tandem outflow stenoses that required treatment. Open repair with aneurysmorrhaphy was performed in one stage in 64% of patients and in two stages in 36%. A tunneled hemodialysis catheter was required in 11 patients (23%) until the surgically repaired AVF was ready for use again, comprising 10 patients treated with single-stage surgery and only one patient in the staged group. All AVFAs were effectively treated, and patients were able to maintain functional use of their access when healed. There is a high association of venous outflow stenoses and AVFA. Comprehensive therapy should encompass treatment of any venous outflow stenoses before open AVFA repair. A two-stage repair may decrease tunneled hemodialysis catheter use in patients with multiple aneurysms.

The Culture of Education in a Large Dialysis Organization: Informing Patient‐Centered Decision Making on Treatment Options for Renal Replacement Therapy

Challenged by the observation that newly admitted dialysis patients were often unaware of their treatment options, Fresenius Medical Care, North America developed a program to improve information delivered to chronic kidney disease (CKD) patients prior to their need for renal replacement therapy. Six years ago, the Treatment Options Program (TOPs) was established utilizing a standardized approach to educate individuals with CKD Stages 3 and 4. The program education focuses on modality and vascular access options. A key component includes follow-up at predetermined intervals, offering additional education and patient reminders to continue to work with their physician in selecting a preferred renal replacement modality. Since program inception, over 73,000 individuals have been educated through TOPs. Home therapy utilization as first treatment is higher in the patient population that received TOPs education. Similarly, participants had a higher rate of permanent vascular access with decreased use of hemodialysis catheters upon admission. Avoiding hemodialysis catheter use and expanding home therapy utilization both offer potential benefits to all stakeholders: patients, providers, and payors, particularly as we move toward accountable healthcare systems. The ability to expand the TOPs program relies on seeing patients early enough to allow each patient time to process the information and work with their physician to select the modality and access that best meets their healthcare and lifestyle needs. Educating our patients facilitates empowerment and active participation in their therapy, a much coveted component of patient-centered health care for the renal provider community as we look to the future.

Central vein stenosis in an Asian hemodialysis population

Central vein stenosis occurs commonly after instrumentation of the major thoracic veins. We aimed to investigate factors that contributed to this condition in an Asian hemodialysis population, and the results of intervention. Hemodialysis patients diagnosed with central vein stenosis between January 2003 and December 2008, were identified from the records of the National University Hospital, Singapore. Eligible controls had a minimum of 2 years of hemodialysis via an arteriovenous fistula and/or central venous catheter, without clinical or radiological evidence of central vein stenosis. Central vein stenosis was diagnosed in 108 patients. The most common presenting features were arm swelling (32%) and failed hemodialysis catheter insertion (28%). The median frequency of permanent hemodialysis catheter insertion in those who subsequently developed venous stenosis (1.44 per patient per year) was 4 times that of controls (0.36 per patient per year; p<0.001). Ischemic heart disease (p = 0.03) and in certain patients, arteriovenous fistula surgery were associated with the development of central vein stenosis; whereas line sepsis, diabetes, and hypertension were not. Central vein angioplasty was attempted in 53 patients; the primary patency was 52% at 1 year. Central vein stenosis is associated with a higher frequency of hemodialysis catheter insertion and access surgery. Efforts to decrease permanent hemodialysis catheter use should reduce the incidence of central vein stenosis.

Prevention of Central Line–Associated Bloodstream Infections in Hemodialysis Patients

An increasing proportion of central line-associated bloodstream infections (CLABSIs) are seen in outpatient settings. Many of such infections are due to hemodialysis catheters (HD-CLABSIs). Such infections are associated with substantial morbidity, mortality, and excess healthcare costs. Patients who receive dialysis through a catheter are 2-3 times more likely to be hospitalized for infection and to die of septic complications than dialysis patients with grafts or fistulas. Prevention measures include minimizing the use of hemodialysis catheters, use of CLABSI prevention bundles for line insertion and maintenance, and application of antimicrobial ointment to the catheter exit site. Instillation into dialysis catheters of antimicrobial solutions that remain in the catheter lumen between dialyses (antimicrobial lock solutions) has been studied, but it is not yet standard practice in some dialysis units. At least 34 studies have evaluated the impact of antimicrobial lock solutions on HD-CLABSI rates. Thirty-two (94%) of the 34 studies demonstrated reductions in HD-CLABSI rates among patients treated with antimicrobial lock solutions. Recent multicenter randomized controlled trials demonstrated that the use of such solutions resulted in significantly lower HD-CLABSI rates, even though such rates were low in control groups. The available evidence supports more routine use of antimicrobial lock solutions as an HD-CLABSI prevention measure in hemodialysis units.

Early Cannulation Prosthetic Graft (Flixene™) for Arteriovenous Access

Preferred hemodialysis (HD) access is an autologous fistula. Vascular grafts are used in patients with vessels unsuitable to accomplish an arteriovenous fistula (AVF). It is recommended that most current grafts mature in situ for 2-3 weeks before being accessed. Graft complications occur because the structure was not designed for the trauma of repeated cannulation. This study graft has a different structure that enables early use. Its design minimizes weeping through the graft walls and is meant to endure repeated access, thus minimizing the use of HD catheters. The purpose of this study was to show that the Flixene™ graft can be safely placed in patients where fistulas have failed and can be cannulated in 24-72 hr, while maintaining patency rates similar to other polytetrafluoroethylene (PTFE) grafts on the market. Flixene™ configuration should also reduce the incidence of pseudoaneurysms and seromas. A prospective two-center study placed 33 grafts in 33 patients; graft efficacy, post-operative complications, and patency were evaluated. Ease of cannulation and dialysis center complications related to early cannulation were documented. Six month follow-up data was analyzed. Successful access was achieved in all 33 patients within 72 hr (29 patients within 24 hr). Overall primary patency at 6 months was 49%; primary-assisted patency at 6 months was 80%. No pseudoaneurysms or seromas were documented at 6 months. Complications were typical of graft access. Early cannulation was successful in all patients. Primary and secondary patency rates at 6-months were equivalent to other data reported on PTFE grafts. Flixene™ successfully prevented pseudoaneurysm and seroma formation at 6 months of prospective follow-up. This graft is a better last-resort option for patients who cannot receive a fistula, compared to double-lumen cuffed catheters.

Tunneled hemodialysis catheters: What do nephrologists need to know?

AbstractEven though many positive changes were ushered in by the KDOQI guidelines and the Fistula First Breakthrough Initiative, tunneled hemodialysis catheters remain an essential piece of the dialysis access puzzle. Their use is, however, attended by a multitude of complications and morbidity of which the general nephrologist must be aware. The purpose of this article is to review for the general nephrologist the infectious and non‐infectious problems that often complicate the use of hemodialysis catheters.

Opinion: The Increasing Use of Hemodialysis Catheters: Evidence from the DOPPS on Its Significance and Ways to Reverse It

<i>Opinion</i>: The Increasing Use of Hemodialysis Catheters: Evidence from the DOPPS on Its Significance and Ways to Reverse It

Variability in Reasons for Hemodialysis Catheter Use by Race, Sex, and Geography: Findings From the ESRD Clinical Performance Measures Project

Race, sex, and geographic differences in hemodialysis vascular access use have been reported, but differences in reasons for catheter use have not been assessed. Cross-sectional. Data obtained from the 2005 Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures Project for adult hemodialysis patients. Race, sex, and geographic region. Reasons for catheter use were categorized as short term and long term. Race, sex, and geographic associations with reasons were assessed by using bivariate analyses and multivariate logistic regression. Of 8,479 hemodialysis patients, 3,302 (39%) used a fistula, 2,725 (32%) used a graft, and 2,299 (27%) used a catheter. We placed 857 patients with a catheter (37%) in the short-term-reason cohort and 1,404 (61%) in the long-term-reason cohort, and 38 (2%) lacked information to be placed. Reasons for catheter use were independently associated with race, sex, and geographic region. Whites were 43%, 49%, and 34% less likely than African Americans to use a catheter because of graft maturation, graft interruption, and all vascular access sites exhausted and 70% and 40% more likely because of fistula maturation and no fistula or graft surgically planned, respectively. Men were 50% less likely than women to use a catheter because of graft interruption and 80% more likely because of fistula maturation. Geographic end-stage renal disease network was associated with catheter use because of fistula maturation (P = 0.03), no fistula or graft surgically created (P < 0.001), and no fistula or graft surgically planned (P = 0.05). The cross-sectional study design precludes our ability to assess trends over time in reasons for catheter use. Associations were assessed for a limited set of variables. Race, sex, and geographic differences in reasons for hemodialysis catheter use exist. Understanding these differences may aid in developing strategies to decrease catheter initiation rates.

Central venous catheters as a vascular access modality for pediatric hemodialysis

The use of hemodialysis catheters is an essential component of dialysis practice. Children are particularly likely to require multiple courses of dialysis over their lifetime, hence the repeated need for vascular access. These catheters remain a significant source of morbidity and mortality. All catheters inserted for hemodialysis at the Center of Pediatric Nephrology and Transplantation, Cairo University over a period of 40 months were studied. Patient data as well as data of catheter insertion, dwell, cause of removal and complications were reported. A total of 195 uncuffed central venous catheters were used for temporary access in 131 patients for a mean duration of 35.7 days. Of attempted insertions, 87.4% achieved successful access, of which 56% remained for the required period, 8.9% were accidentally dislodged, and 35.1% were removed due to complications--mostly infection. The overall rate of possible catheter-related bacteremia was 9.6 episodes/ 1,000 catheter days. Infection increased with longer catheter dwell. Nineteen cuffed tunneled catheters were surgically inserted and used for up to 11 months (mean 117 days). Loss of these catheters was attributed mainly to infection (ten episodes) and catheter thrombosis (six episodes). During the study, 317 femoral catheters were inserted. Uncuffed central venous catheters are both needed and useful for short-term hemodialysis. Vascular access for extended durations may be provided by cuffed tunneled catheters. Infection is the major serious concern with both uncuffed and cuffed catheters.

Balancing Fistula First With Catheters Last

The success of Fistula First nationwide has been accompanied by an unplanned increase in hemodialysis catheters. Complications related to prolonged hemodialysis catheter use include increased morbidity, mortality, and cost. We hypothesize that the national focus on increasing fistulas may have inadvertently diverted attention away from initiatives to decrease dependence on hemodialysis catheters. Based on a synthesis of guidelines, reviews, published evidence, and the authors' opinions, we propose that the national vascular access initiative be revised to have a dual goal of Fistula First and "Catheters Last." These goals are not mutually exclusive, but rather complementary. We recommend a systematic refocus on interventions that not only increase fistulas, but help avoid extended catheter use. Clearly, the ideal practice for hemodialysis vascular access remains early placement of fistulas with enough maturation time such that they can be used for initiating long-term hemodialysis therapy when the need arises. To effect this change, a reimbursement policy covering the costs associated with permanent access placement before the need for dialysis is essential. Individualized patient management strategies may consider such innovative approaches as initiating patients on peritoneal dialysis therapy or using nonautogenous grafts as bridge accesses in lieu of catheters. For patients who are dialyzing using catheters, immediate active planning for permanent access placement and removal of the catheter is necessary. In the same vein as Fistula First, the renal community should once again be galvanized in working together toward controlling the catheter epidemic in our dialysis population.

242: Reasons for Hemodialysis Catheter Use & Its Complications: Patient and Coordinator Perspectives

242: Reasons for Hemodialysis Catheter Use & Its Complications: Patient and Coordinator Perspectives

Comparison of Infectious Complications between Incident Hemodialysis and Peritoneal Dialysis Patients

The impact of dialysis modality on infection, especially early in the course of dialysis, has not been well studied. This study compared infection between hemodialysis (HD) and peritoneal dialysis (PD) from the start of dialysis and evaluated factors that have an impact on infection risk. In this observational cohort study, all incident dialysis patients (n = 181; HD 119 and PD 62) at a single center from 1999 to 2005 had data collected prospectively beginning day 1 of dialysis. Excluded were those with any previous ESRD therapy. Infection rates were evaluated using multivariate Poisson regression. Overall infection rates were similar (HD 0.77 versus PD 0.86/yr; P = 0.24). Only HD patients had bacteremia (0.16/yr), and only PD patients had peritonitis (0.24/yr). Bacteremia that occurred < or =90 d after start of HD was 0.44/yr, increased compared with overall rate of 0.16/yr (P < 0.004). HD catheters, used in 67% of patients who started HD, were associated with a strikingly increased rate of bacteremia. Peritonitis < or =90 d was 0.22/yr, no different from the overall rate. Modality was not an independent predictor of overall infections (PD versus HD: relative risk 1.30; 95% confidence interval 0.93 to 1.8; P = 0.12) using multivariate analysis. PD and HD patients had similar infection rates overall, but type of infection and risk over time varied. HD patients had an especially high risk for bacteremia in the first 90 d, whereas the risk for peritonitis for the PD cohort was not different over time. These results support the placement of permanent accesses (fistula or PD catheter) before the start of dialysis to avoid use of HD catheters.

Avoiding Trouble Down the Line: The Management and Prevention of Hemodialysis Catheter-Related Infections

Over the last 2 decades, hemodialysis catheter use has increased. Annually, approximately 30% of patients using a central venous catheter (CVC) experience a septic or bacteremic episode and are subsequently at risk of its associated long-term complications and mortality. Because of the serious clinical and financial impact of hemodialysis catheter-related bacteremias (HCRIs), standardized, validated definitions based on the hemodialysis patient population are necessary in order to better diagnose, monitor, and report HCRI for patient quality assurance and research purposes. The pathophysiology of HCRI involves a complex interaction between a triad that consists of the host patient, the infecting microorganism, and the vehicle catheter. Although the microorganism contribution in the pathogenesis of HCRI is likely most important, certain patient and catheter-related characteristics may be more amenable to manipulation. The key to managing HCRI is on prophylaxis against the initial microorganism catheter adherence and subsequent biofilm development. General and specific prophylactic maneuvers directed at both an intravascular and extraluminal route of microorganism entry are discussed including antibiotic- and silver-impregnated catheters and dressings, subcutaneous access devices, and topical prophylaxis at the exit site. In addition to systemic antibiotic use, the 3 methods of HRCI treatment using catheter salvage, guidewire exchange, and concurrent antibiotic lock are compared. The outcome and complications of HCRI may be serious and highlight the importance of careful, continual infection surveillance. Although the use of a multidisciplinary hemodialysis infection control team is desirable, staffing education and physician feedback have been shown to improve adherence to infection control guidelines and reduce HCRI.

Changes in Medicare Reimbursement and Patient-Nephrologist Visits, Quality of Care, and Health-Related Quality of Life

Medicare's reimbursement system was changed in January 2004 to encourage more frequent visits between dialysis patients and nephrologists. We sought to determine the impact of this policy change on patient-nephrologist visits, quality of care, and health-related quality of life. We examined visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change. For comparison of outcomes, we used linear, logistic, or negative binomial regression models (for continuous, binary, and rate outcomes, respectively) to assess the significance of changes across the 2 periods. For patients seen before and after the reimbursement change for at least 6 months, the number of visits per patient-month increased from 1.52 before to 3.14 after (P < 0.001). The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after (P < 0.001). However, there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction. Despite a marked increase in visits between patients and nephrologists, there was no clinically important impact on parameters related to quality of care or health-related quality of life. Additional work is needed to determine effective payment strategies to improve dialysis patient outcomes.

Late creation of vascular access for hemodialysis and increased risk of sepsis.

The creation of fistulas or grafts before starting dialysis is recommended, but whether it reduces major adverse events is largely unknown. The objective of this study was to determine if early access creation was associated with a reduced risk of hospitalization from sepsis and mortality. Fistulas or grafts created at least 4 mo before starting hemodialysis were defined as Early creations (n = 1240), and accesses created between 4 mo and 1 mo before starting hemodialysis were defined as Just Prior creations (n = 997). Accesses created within 1 mo of starting dialysis or after were defined as Late creations (reference group, n = 3687). Hemodialysis catheter use was defined as insertion, removal, or manipulation of a catheter before the occurrence of sepsis. Eighty percent of accesses were fistulas. Early access creation was associated with a relative risk (RR) of sepsis of 0.57 (95% CI, 0.41 to 0.79) compared with Late access creation. Catheter use increased the risk of sepsis by 1.41 (95% CI, 1.14 to 1.81). The risk of sepsis with Early creation decreased to 0.48 (95% CI, 0.35 to 0.65) if catheter use was not adjusted. Early access creation was associated with lower mortality (RR 0.76; 95% CI 0.58 to 1.00), but this association became nonsignificant if catheter use and sepsis were adjusted. Catheter use and sepsis independently increased mortality. This study demonstrates that fistula creation at least 4 mo before starting chronic hemodialysis is associated the lowest risk of sepsis and death, primarily by reducing the use of hemodialysis catheters.

Complications associated with the use of haemodialysis catheters in patients with chronic renal failure

Complications associated with the use of haemodialysis catheters in patients with chronic renal failure

A scanning electron microscopy analysis of a spontaneous hemodialysis catheter fracture

Central venous catheters have become increasingly important in hemodialysis treatment. With their increased use, catheter-related problems will be seen more frequently, and more rare complications may be observed. We describe the first case of asymptomatic spontaneous breakdown of a tunneled cuffed silicone catheter used for long-term hemodialysis treatment. This was discovered on removal of the catheter, leaving behind a catheter fragment in the left lower pulmonary lobe. An extensive scanning electron microscopy study showed accumulation of lumps of nonsilicone material at the place of the fracture, leading to severe disruption of the original cross-linked elastomer structure. Using energy-dispersive X-ray spectral analysis, which shows all elements with an atomic number of 11 or greater in a material, we found the lumps were aggregates of barium sulfate particles used to visualize the catheter on fluoroscopy. We suggest that the use of too small or too many barium sulfate particles led to high viscosity of the raw silicone before polymerization, causing improper mixing of barium sulfate particles in the silicone matrix. This resulted in insufficient removal of admixed air bubbles and unequal dispersion of barium sulfate, with the potential for weak spots after extrusion of the silicone into its definitive shape. With the increasing use of hemodialysis catheters for prolonged periods, catheter-related complications related to materials or manufacturing errors can be expected to occur more often. © 2001 by the National Kidney Foundation, Inc.

The hemodialysis catheter conundrum: Hate living with them, but can’t live without them

Hemodialysis requires reliable recurrent access to the circulation. On a chronic basis, this has been best provided by the use of arteriovenous fistulae and arteriovenous grafts. In recent years, hemodialysis catheters have come to play an increasingly important role in the delivery of hemodialysis. The use of both temporary as well as cuffed hemodialysis catheters has emerged as a significant boon for both patients and practicing nephrologists. The complications, however, associated with each of these hemodialysis catheters, both in terms of anatomic, thrombotic, and infectious issues, have emerged as a major problem with their continued use. This significant morbidity and complication rate has forced many nephrologists to face a basic conundrum: they have come to hate having to deal with the problems inherent in catheter usage, but the enormous utility of these devices have forced physicians to accept the fact they cannot live without them in their current practice. We used a comprehensive literature review to describe the types, use and dilemmas of hemodialysis catheters. This article provides a comprehensive review of both the benefits inherent with the use of these hemodialysis catheters while cataloging their complications and offering some possible solutions. Hemodialysis vascular access catheters are essential in the maintenance of hemodialysis vascular access. However, they have a significant infectious, thrombotic, anatomic complication rate that are detailed with proposed problem-solving guidelines.