Hemodialysis vascular catheters review

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Although large efforts are spent for creating fistula as the primary access, use of Hemodialysis Vascular catheters are still the major access on the first Hemodialysis session and after 4 month whether we would like it or not.
"USRDS 2013"

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Hemodialysis vascular catheters review

  1. 1. Jafar Al-Said, M.B. CHb. MD. FASN. FACP Nephrology and Internal Medicine Consultant Bahrain Specialist Hospital
  2. 2. Adjusted prevalent rates of ESRD & annual percent change Figure 1.10 (Volume 2) December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2010 ESRD patients. USRDS 2013
  3. 3. Incident & prevalent patient counts (USRDS), by modality Figure 1.1 (Volume 2) Incident & December 31 point prevalent ESRD patients; peritoneal dialysis consists of CAPD & CCPD. USRDS 2013
  4. 4. Fistula First  KDOQI.  www.fistula first.org.  Medicare/Medicade: www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp.
  5. 5. Vascular access use at initiation and on day of eligibility, 2011. Figure 1.21 (Volume 2) Incident hemodialysis patients, 2011. USRDS 2013.
  6. 6. Access use at first outpatient hemodialysis, by pre-ESRD nephrology care, 2011 Figure 1.22 (Volume 2) Incident hemodialysis patients, 2011. USRDS 2013
  7. 7. BSH Hemodialysis population, % over 112 months. Jan. 2004 – May. 2013 AVF 20% Access types: AVG 18% Cuffed cath. Vascath. 56% 6% 0% N= 147 patients. 8741 HD 10% 20% 30% 40% 50% 60%
  8. 8. Indications for vascular catheter:  Acute renal failure.  Dialysis for overdose.  ESRD with no access.  ESRD with failure of access.  Peritoneal dialysis with complications.  Transplant patients require HD.  ESRD who lost all possible access.  Heart failure patients.  Plasmapharesis and Hemoperfusion.
  9. 9. Types of catheters  Cuffed / non Cuffed.  Luminal design.  Material.  Antiseptic impregnated.
  10. 10. Temporary non Cuffed Catheters  Short.  More ridged.  Easy and fast insertion.  Immediate use.  Higher infection rate.  Preferred IJ or femoral.  Avoid subclavian.  < 3wks for IJ.  <5 days for femoral. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology,.ASN. 361-375. 2009.
  11. 11. Cuffed Tunneled Catheters  Dacron cuff.  Softer.  Sheath for insertion.  Different holes, length and material.  Requires sedation.  Lower neck insertion site.  More bleeding. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375.2009.
  12. 12. Advantage & Disadvantage
  13. 13. Catheters Disadvantages  Associated with higher mortality risk than fistula RR2.2.  Thrombosis.  Infection.  Central venous thrombosis.  Discomfort.  Cosmetic.  Shorter expected using time.  Lower Qb. National kidney Foundation. KDOQI
  14. 14. Advantage of the Catheters  Universal Application.  No maturation time.  No skin puncture.  Short term Hemodynamic consequence.  Lower initial cost.  Provide time for fistula maturation. National kidney Foundation KDOQI
  15. 15. Catheter Location
  16. 16. Catheter location  Rt IJ.  Lt IJ.  Subclavian, not preferred due to the venous stenosis.  Femoral.  Translumber.  Transhepatic. Fry AC, Stratton J, Farrington K, Mahna K, Selvakumar S, Thompson T, Warwicker P: Factors affecting long-term survival of tunneled haemodialysis catheters: A prospective audit of 812 tunneled catheters. Nephrol Dial Transplant 23: 275–281, 2008  Ultrasound should be used it the placement of the catheters.  Fluoroscopy is needed for cuffed tunneled catheters. National Kidney foundation KDOQI
  17. 17. Cuffed tunneled catheter position  Fluoroscopy guidance.  Tips at junction of SVC with Rt. Atrium.  Fixed suturing.  Patient body habitus and position.  Catheter migration. Granata A, Figuera M, Basile A: Why doesn’t this hemodialysis catheter work? Am J Kidney Dis 51: xlii–xliv, 2008. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology.ASN. 361-375. 2009.
  18. 18. Tip of the Cuffed tunneled catheter
  19. 19. Complications
  20. 20. Early and immediate complications  Arterial puncture.  Venous perforation.  Bleeding & hematoma.  Pneumothorax.  Hemothorax & Hemomediastinum.  Air embolism.  Arrhythmia and cardiac arrest.  Cardiac chamber perforation.  Pericardial Tamponade.  Injury to adjacent structures: Nerves, Trachea,..etc. Schwab SJ, Beathard G: The hemodialysis catheter conundrum: Hate living with them, but can’t live without them. Kidney Int 56: 1–17, 1999. Walsh SB, Ekbal N, Brookes J, Cunningham J: Tinnitus after hemodialysis catheter placement. Kidney Int 74: 688, 2008. Muthuswamy P, Alausa M, Reilly M: The effusion that would not go away. N Engl J Med 345: 756–759, 2001.
  21. 21. Late Complications  Thrombosis.  Fibrin sheath formation.  Infection.  Vascular thrombosis and stricture.  AV fistula. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
  22. 22. HD catheter Thrombosis
  23. 23. HD catheter Thrombosis within or outside of the lumen. Prevention with Catheter Lock: Heparin 1000-10000/ml.  Affect PT, PTT and cause HIT ( Thrombocytopenia).  Bleeding.  Allergic reaction. Warkentin TE, Levine MN, Hirsh J, Horsewood P, Roberts RS, Gent M, Kelton JG: Heparininduced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med 332: 1330–1336, 1995 Karaaslan H, Peyronnet P, Benevent D, Lagarde C, Rince M, Leroux- Robert C: Risk of heparin lock-related bleeding when using indwelling venous catheter in haemodialysis. Nephrol Dial Transplant 16: 2072–2074, 2001.
  24. 24. Citrate as Anticoagulation Trisodium Citrate: 4%.  As effective as Heparin.  Hypocalcemia.  Lower catheter related bacteremia. Weijmer MC, van den Dorpel MA, Van de Ven PJ, ter Wee PM, van Geelen JA, Groeneveld JO, van Jaarsveld BC, Koopmans MG, le Poole CY, Schrander-Van der Meer AM, Siegert CE, Stas KJ, CITRATE Study Group: Randomized clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol 16: 2769–2777, 2005. Moran JE, Ash SR, ASDIN Clinical Practice Committee: Locking solutions for hemodialysis catheters: Heparin and citrate—A position paper by ASDIN. Semin Dial 21: 490–492, 2008
  25. 25. Systemic Anticoagulation use for preventing Thrombosis  105 patient  RCT.  Warfarin versus Placebo.  No difference in thrombosis free survival or use of Thrombolysis. Mokrzycki MH, Jean-Jerome K, Rush H, Zdunek MP, Rosenberg SO: A randomized trial of minidose warfarin for the prevention of late malfunction in tunneled, cuffed hemodialysis catheters. Kidney Int 59: 1935–1942, 2001
  26. 26. Systemic Anticoagulation use for preventing Thrombosis  Comparing ASA, Warfarin and placebo: 120 days Cather patency:  91 % with ASA.  73 % with Warfarin.  29% with placebo. Bennett WM: Should dialysis patients ever receive warfarin and for what reasons? Clin J Am Soc Nephrol 1: 1357–1359, 2006.
  27. 27. Management of Catheter Thrombosis  Forceful Flushing.  Urokinase or tPA. Clase CM, Crowther MA, Ingram AJ, Cina` CS: Thrombolysis for restoration of patency to haemodialysis central venous catheters: A systematic review. J Thromb Thrombolysis 11: 127, 2001. Shavit L, Lifschitz M, Plaksin J, Grenader T, Slotk I: Urokinase for restoration of patency of occluded permanent central venous access in haemodialysis patients: A new protocol. Nephrol Dial Transplant 22: 666–667, 2007  Mechanical disruption with brush. Cox K, Vesely TM, Windus DW, Pilgram TK: The utility of brushing dysfunctional hemodialysis catheters. J Vasc Interv Radiol 11: 979–983, 2000
  28. 28. Other sites of Thrombosis Central Venous. 2. Atrial. 1. Treatment:  Removal of catheter.  Anticoagulation.  Surgical intervention. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
  29. 29. Fibrin Sheath
  30. 30. Fibrin Sheath  Outer side.  Cover the pores. Compose of Thrombus with fibrin, Endothelial cells, Smooth muscle cells, endothelial cells and collagen. Treatment:  Thrombolysis.  Wires and balloons. O’Farrell L, Griffith JW, Lang CM: Histologic development of the sheath that forms around longterm implanted central venous catheters. J Parenter Enteral Nutr 20: 156–158, 1996. Forauer AR, Theoharis C: Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 14: 1163–1168, 2003 Savader SJ, Haikal LC, Ehrman KO, Porter DJ, Oteham AC: Hemodialysis catheter-associated fibrin sheaths: Treatment with a low-dose rt-PA infusion. J Vasc Interv Radiol 11: 1131–1136, 2000
  31. 31. Hemodialysis Catheter-related infection
  32. 32. Hemodialysis catheter infection  Second cause of mortality.  First cause of Morbidity.  Bacterial flora migration.  Exoluminal and Endoluminal growth.  Increased catheter loss, bacteremia, hospitalization. Ishani A, Collins AJ, Herzog CA, Foley RN: Septicemia, access and cardiovascular disease in dialysis patients: The USRDS Wave 2 study. Kidney Int 68: 311–318, 2005
  33. 33. Vascular access infection definitions Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
  34. 34. Vascular access infection definitions Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
  35. 35. Hemodialysis catheter infection Rate of uncuffed cath. infection:  8% by 2wks.  25% by 1 month.  50% by 2 months. Catheter related septicemia is 2 -20%. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
  36. 36. Recommended duration for HD catheters: Vascath:  IJ  Subclavian  Femoral. 2-3wks? 2-3wks? 2-5days? Cuffed tunneled:  1 year –Indefinite. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
  37. 37. Cuffed Tunneled Cath. Duration Catheter survival will depend on: 1. Design. 2. Site of insertion. 3. Rt. IJ > Lt IJ> Femoral. 4. Non Dm. Fry AC, Stratton J, Farrington K, Mahna K, Selvakumar S, Thompson T, Warwicker P: Factors affecting longterm survival of tunneled haemodialysis catheters: A prospective audit of 812 tunneled catheters. Nephrol Dial Transplant 23: 275–281, 2008
  38. 38. Types of HD catheter infection  Localized exit site infection.  Tunnel infection.  Systemic infection.  Last access cuffed tunneled infected catheter.
  39. 39. Signs and symptoms of Hemodialysis Catheter related infection  Immunosuppressed patients.  Inflammatory signs:  redness, hotness, pain, swelling, discharge.  Fever during Hemodialysis. The catheter is the cause of fever unless proven otherwise.  Redness over the exit site.  Discharge from the exit site.
  40. 40. Investigations for catheter infection  CBC.  Blood Culture peripheral and from catheter.  Catheter tip Cx.  Exit site discharge.  Others: Urine, Sputum, Drains..etc.
  41. 41. Exit site infection  Erythema, discharge and tenderness.  Obtain Cx.  Could be treated with Local and oral AB.  Rarely required removing the catheter. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
  42. 42. Catheter Tunnel infection  Inflammatory signs over the tunnel.  Purulent discharge.  IV AB.  Exchange of the catheter.  Different site. Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009
  43. 43. Catheter related Bacteremia  Cuffed rate 1.6-5.5/1000 d.  Non cuffed 3.8-6.6/1000 d. High mortality and morbidity. Related with Catheter tip colonization. Higher risks:  Immunosuppressed patients.  S. Alb < 3.5g/dl. Organisms; G+, less common G- bacilli. Beathard GA, Urbanes A: Infection associated with tunneled hemodialysis catheters. Semin dial 21: 528–538, 2008.
  44. 44. Catheter related Bacteremia Clinical picture:  Fever with chills.  May be only during HD.  patient with Central catheter.  No other focus.  Sepsis. Dx: Blood Cx > 15CFU. From peripheral and catheter. Treatment: AB for 2-3 wks with exchange of the catheter.
  45. 45. Catheter Salvage in poor access 30% AB treatment could clear infection. 80% AB with exchange over guide wire. Tanriover B, Carlton D, Saddekni S, Hamrick K, Oser R, Westfall AO, Allon M: Bacteremia associated with tunneled dialysis catheters: Comparison of two treatment strategies. Kidney Int 57: 2151–2155, 2000 Exchange:  72 hours post AB.  No need for negative blood Cx. National Kidney Foundation: KDOQI clinical practice guidelines and clinical practice recommendations for vascular access 2006. Am J Kidney Dis 48[Suppl 1]: S176–S322, 2006
  46. 46. Bacterial Biofilm  Spread for Skin exit site. Reduced with:  Mupirocin.  Polysporin.  Medicated Honey. Johnson DW, MacGinley R, Kay TD, Hawley CM, Campbell SB, Isbel NM, Hollett P: A randomized controlled trial of topical exit site mupirocin application in patients with tunnelled, cuffed haemodialysis catheters. Nephrol Dial Transplant 17: 1802–1807, 2002. Johnson DW, Van Eps C, Mudge DW, Wiggins KJ, Armstrong K, Hawley CM, Campbell SB, Isbel NM, Nimmo GR, Gibbs H: Randomized, controlled trial of topical exit-site application of honey (Medihoney) versus mupirocin for the prevention of catheter-associated infections in hemodialysis patients. J Am Soc Nephrol 16: 1456–1462, 2005. 29. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW, Conly J: Hemodialysis infection prevention with polysporin ointment. J Am Soc Nephrol 13: 169–179, 2003
  47. 47. Antibiotic Lock  Is indicated in reinfection with same organism.  In limited catheter sites.  Catheter Salvage is acceptable. Onder AM, Chandar J, Simon N, Diaz R, Nwobi O, Abitbol CL, Zilleruelo G: Comparison of tissue plasminogen activator–antibiotic locks with heparin–antibiotic locks in children with catheter-related bacteraemia. Nephrol Dial Transplant 23: 2604–2610, 2008. Rijnders BJ, Van Wijngaerden E, Vandecasteele SJ, Stas M, Peetermans WE: Treatment of longterm intravascular catheter-related bacteremia with antibiotic lock: Randomized, placebocontrolled trial. J Antimicrob Chemother 55: 90–94, 2005
  48. 48. Types of Antibiotic Lock  Cefazolin, Cephotaxim, Vancomycin, Tobramycin, Gentamyin. Concentration: 5mg/ml. mixed with Citrate, EDTA, Heparin, rtPA. . Systemic AB with Antibiotic lock more effective for  G. Neg.  Less effective for Staph. Epidermidis.  Worst for Staph aureus. Maya ID, Carlton D, Estrada E, Allon M: Treatment of dialysis catheter-related Staphylococcus aureus bacteremia with antibiotic lock: A quality improvement report. Am J Kidney Dis 50: 289–295,2007
  49. 49. Different AB surface coating catheters
  50. 50. Hemodialysis Catheter infection complications  Osteomylitis.  Endocarditis.  Septic arthritis.  Spinal epidural abscess.
  51. 51. Catheter Dysfunction  Early:  Late:
  52. 52. Catheter Dysfunction signs  Qb < 300ml/min.  Art. Pressure <-250.  Ven. Pressure > 250.  URR < 65, Kt/V < 1.2.  Unable to aspirate blood freely. (Late sign).  Frequent pressure alarms.
  53. 53. Causes for Catheter Dysfunction           Mechanical. Kink. Misplaced suture. Catheter Migration. Drug Precipitation. Patient Position. Catheter integrity. Holes. Cracks. Fibrin Sheath. NKF KDOQI
  54. 54. Catheter Dysfunction  Progress to complete non functional.  Better salvaged early.  17-33% leads to removal.  30-40% leads to catheter thrombosis.  Increased Morbidity and mortality.  Higher cost.
  55. 55. Managing catheter dysfunction  Reposition.  Thrombolytic. 1. Intralunminal. 2. Intradialytic Lock. 3. Intracatheter thrombolytic infusion.  Exchange with sheath disruption.
  56. 56. Central Venous Thrombosis  41% of Catheter patient.  25% of dusfunction AVF is related to previous subclavian cath. Risk increase with: 1. Multiple insertions. 2. Longer catheter time. 3. Non Cuffed cath. > 21days. 4. Lt IJ and Sunclavian. Macrae JM, Ahmed A, Johnson N, Levin A, Kiaii M: Central vein stenosis: A common problem in patients on hemodialysis. ASAIO J 51: 77–81, 2005 Oguzkurt L, Tercan F, Torun D, Yildirim T, Zumrutdal A, Kizilkilic O: Impact of short-term hemodialysis catheters on the central veins: A catheter venographic study. Eur J Radiol 52: 293– 299, 2004
  57. 57. Central Venous Thrombosis
  58. 58. Central Venous Thrombosis Causes:  Endothelial injury.  Movement with respiration and pulsation.  Vibration & turbulence flow. Agarwal AK, Patel BM, Haddad NJ: Central vein stenosis: A nephrologist’s perspective. Semin Dial 20: 53–62, 2007.
  59. 59. Central Venous Thrombosis Clinical picture:  Swelling of the arm.  Higher venous pressures.  Bleeding.  Access Thrombosis.  Loss of access.  SVC Syndrome.  Increased collaterals.
  60. 60. Central Venous Thrombosis Treatment  Medical treatment.  Angioplasty.  Stent. Bakken A, Protack C, Saad W, Lee D, Waldman D, Davies M: Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg 45: 776–783, 2007. Maya ID, Saddekni S, Allon M: Treatment of refractory central vein stenosis in hemodialysis patients with stents. Semin Dial 20: 78–82, 2007
  61. 61. Catheter replacement  Sever infection.  Staph Aureus, Pseudomonas, Fungal Cx.  Replace after 72 hours of AB treatment.  maintain negative Cx is recommended before replacement?  Different insertion location is recommended.  Avoid cuffed tunneled catheter with infection focus.  AB selection depends on antibiogram.
  62. 62. Fistula First  KDOQI.  www.fistula first.org.  Medicare/Medicade: www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp. a.
  63. 63. Conclusion  Fistula First.  Types of catheters.  Advantage and disadvantage.  Sites of catheters.  Complications of catheters.

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