Current State Of Vascular Access In Chronic Hemodialysis Patients In Algeria
Hemodialysis vascular catheters review
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Transcript of Hemodialysis vascular catheters review
Hemodialysis Vascular Catheters
Jafar Al-Said, M.B. CHb. MD. FASN. FACPNephrology and Internal Medicine Consultant
Bahrain Specialist Hospital
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
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
Fistula FirstKDOQI.
www.fistula first.org.
Medicare/Medicade:
www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.as
p
.
Vascular access use at initiation and on day of eligibility, 2011. Figure 1.21 (Volume 2)
Incident hemodialysis patients, 2011. USRDS 2013.
Access use at first outpatient hemodialysis, by pre-ESRD nephrology care, 2011
Figure 1.22 (Volume 2)
Incident hemodialysis patients, 2011. USRDS 2013
Vascath.
Cuffed cath.
AVG
AVF
0% 10% 20% 30% 40% 50% 60%
6%
56%
18%
20%
%
Access types:
BSH Hemodialysis population, over 112 months. Jan. 2004 – May. 2013
N= 147 patients.8741 HD
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.
Types of catheters
Cuffed / non Cuffed.
Luminal design.
Material.
Antiseptic impregnated.
Temporary non Cuffed CathetersShort.
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.
Dacron cuff.
Softer.
Sheath for insertion.
Different holes, length and material.
Requires sedation.
Lower neck insertion site.
More bleeding.
Cuffed Tunneled Catheters
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375.2009.
Advantage & Disadvantage
Catheters DisadvantagesAssociated 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
Advantage of the CathetersUniversal Application.
No maturation time.
No skin puncture.
Short term Hemodynamic consequence.
Lower initial cost.
Provide time for fistula maturation.
National kidney Foundation KDOQI
Catheter Location
Catheter locationRt IJ.Lt IJ.Subclavian, not preferred due to the venous stenosis. Femoral.Translumber.Transhepatic.
Ultrasound should be used it the placement of the catheters.
Fluoroscopy is needed for cuffed tunneled catheters.
National Kidney foundation KDOQI
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
Cuffed tunneled catheter positionFluoroscopy 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.
Tip of the Cuffed tunneled catheter
Complications
Early and immediate complicationsArterial 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.
Thrombosis.
Fibrin sheath formation.
Infection.
Vascular thrombosis and stricture.
AV fistula.
Late Complications
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
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: Heparin-induced 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.
HD catheter Thrombosis
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
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
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.
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
Other sites of Thrombosis1. Central Venous.2. Atrial.
Treatment:
Removal of catheter.
Anticoagulation.
Surgical intervention.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
Fibrin Sheath
Fibrin SheathOuter 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 long-term 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
Hemodialysis Catheter-related infection
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
Vascular access infection definitions
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
Vascular access infection definitions
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
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.
Recommended duration for HD catheters:
Vascath: IJ 2-3wks? Subclavian 2-3wks? Femoral. 2-5days?
Cuffed tunneled: 1 year –Indefinite.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
Cuffed Tunneled Cath. DurationCatheter 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 long-term survival of tunneled haemodialysis catheters: A prospective audit of 812 tunneled catheters. Nephrol Dial Transplant 23: 275–281, 2008
Types of HD catheter infection
Localized exit site infection.
Tunnel infection.
Systemic infection.
Last access cuffed tunneled infected catheter.
Signs and symptoms of Hemodialysis Catheterrelated 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.
Investigations for catheter infection
CBC.
Blood Culture peripheral and from catheter.
Catheter tip Cx.
Exit site discharge.
Others: Urine, Sputum, Drains..etc.
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.
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
Catheter related BacteremiaCuffed 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.
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.
Catheter related Bacteremia
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
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
Antibiotic LockIs 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 long-term intravascular catheter-related bacteremia with antibiotic lock: Randomized, placebo-controlled trial. J Antimicrob Chemother 55: 90–94, 2005
Types of Antibiotic LockCefazolin, 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
Different AB surface coating catheters
Hemodialysis Catheter infection complications
Osteomylitis.
Endocarditis.
Septic arthritis.
Spinal epidural abscess.
Catheter Dysfunction
Early:
Late:
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.
Causes for Catheter Dysfunction
Mechanical.Kink.Misplaced suture.Catheter Migration.Drug Precipitation.Patient Position.Catheter integrity.Holes. Cracks. Fibrin Sheath.
NKF KDOQI
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.
Managing catheter dysfunction
Reposition.
Thrombolytic.
1. Intralunminal.
2. Intradialytic Lock.
3. Intracatheter thrombolytic infusion.
Exchange with sheath disruption.
Central Venous Thrombosis41% 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, 2005Oguzkurt 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
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.
Central Venous Thrombosis
Clinical picture:
Swelling of the arm.
Higher venous pressures.
Bleeding.
Access Thrombosis.
Loss of access.
SVC Syndrome.
Increased collaterals.
Central Venous Thrombosis
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
Central Venous Thrombosis Treatment
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.
Fistula First
KDOQI.www.fistula first.org.Medicare/Medicade:
www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp.
a.
ConclusionFistula First.
Types of catheters.
Advantage and disadvantage.
Sites of catheters.
Complications of catheters.