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"

1. Jafar Al-Said, M.B. CHb. MD. FASN. FACP
Nephrology and Internal Medicine Consultant
Bahrain Specialist Hospital

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. 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. Fistula First
 KDOQI.
 www.fistula first.org.
 Medicare/Medicade:
www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp.

5. Vascular access use at initiation and on day
of eligibility, 2011. Figure 1.21 (Volume 2)
Incident hemodialysis patients, 2011.
USRDS 2013.

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. 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. 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. Types of catheters
 Cuffed / non Cuffed.
 Luminal design.
 Material.
 Antiseptic impregnated.

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. 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. Advantage & Disadvantage

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. 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. Catheter Location

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. 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. Tip of the Cuffed tunneled catheter

19. Complications

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. 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. HD catheter Thrombosis

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. 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. 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. 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. 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. 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. Fibrin Sheath

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. Hemodialysis Catheter-related
infection

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. Vascular access infection definitions
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.

34. Vascular access infection definitions
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.

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. 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. 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. Types of HD catheter infection
 Localized exit site infection.
 Tunnel infection.
 Systemic infection.
 Last access cuffed tunneled infected catheter.

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. Investigations for catheter infection
 CBC.
 Blood Culture peripheral and from catheter.
 Catheter tip Cx.
 Exit site discharge.
 Others: Urine, Sputum, Drains..etc.

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. 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. 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. 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.

46. 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

47. 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

48. 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

49. 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

50. Different AB surface coating catheters

51. Hemodialysis Catheter infection
complications
 Osteomylitis.
 Endocarditis.
 Septic arthritis.
 Spinal epidural abscess.

52. Catheter Dysfunction
 Early:
 Late:

53. 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.

54. Causes for Catheter Dysfunction










Mechanical.
Kink.
Misplaced suture.
Catheter Migration.
Drug Precipitation.
Patient Position.
Catheter integrity.
Holes.
Cracks.
Fibrin Sheath.
NKF KDOQI

55. 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.

56. Managing catheter dysfunction
 Reposition.
 Thrombolytic.
1.
Intralunminal.
2.
Intradialytic Lock.
3.
Intracatheter thrombolytic infusion.
 Exchange with sheath disruption.

57. 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

58. Central Venous Thrombosis

59. 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.

60. Central Venous Thrombosis
Clinical picture:
 Swelling of the arm.
 Higher venous pressures.
 Bleeding.
 Access Thrombosis.
 Loss of access.
 SVC Syndrome.
 Increased collaterals.

61. 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

62. 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.

63. Fistula First
 KDOQI.
 www.fistula first.org.
 Medicare/Medicade:
www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp.
a.

64. Conclusion
 Fistula First.
 Types of catheters.
 Advantage and disadvantage.
 Sites of catheters.
 Complications of catheters.