Efficacy of Low-Dose Alteplase for Treatment of Hemodialysis Catheter Occlusions

Haymond, Jeffrey E.; Shalansky, Karen F.; Jastrzebski, Jacek

doi:10.1177/112972980500600206

Cited by 26 publications

(33 citation statements)

References 14 publications

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“…The reported incidence of catheter dysfunction ranges from 5 to 80%, depending on the definition, population, and catheter characteristics (7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The interpretation of studies that use blood flow as a measure of catheter dysfunction are challenging without knowledge of blood pump setting, use of average versus episodic measures of blood flow, percentage of recirculation, and other dialysis variables.…”

Section: Discussionmentioning

confidence: 99%

“…The definition of CVC dysfunction varies across the literature and includes variable rates of blood flow ranging from Ͻ100 to 350 ml/min (7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The NKF-DOQI vascular access guideline defines CVC dysfunction as failure to attain and maintain extracorporeal blood flow that is sufficient to perform HD without significantly lengthening the HD treatment and considered insufficient extracorporeal blood flow to be Ͻ300 ml/min (6).…”

mentioning

confidence: 99%

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Relationship between Blood Flow in Central Venous Catheters and Hemodialysis Adequacy

Moist

Hemmelgarn

Lok

2006

Clinical Journal of the American Society of Nephrology

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Central venous catheter dysfunction is a frequent problem and often is defined as a blood flow <300 ml/min. This prospective, cross-sectional study included 259 patients and examined the relationship between catheter blood flow and dialysis adequacy as measured by urea reduction ratio (URR), single pool urea kinetics, and online effective ionic dialysance clearance. Dialysis adequacy at blood flow rates of <300, <275, and <250 ml/min; sensitivity; specificity; and positive and negative predictive values were calculated. Mean blood flow was 352 ml/min (SD ؎ 48.8). Mean blood flow <300 ml/min occurred in 10.5% of the patients, and only 26% had a URR of <65%. Maximum blood flows <300 ml/min occurred in 6.9% of patients, and only 22.2% had URR <65%. The positive predictive value of mean blood flow of <300 and <275 ml/min to predict a URR <65% was 22 and 40%, respectively. Using receiver operator characteristic curves, the area under the curve was not significantly different for blood flows of 300, 275, or 250 ml/min. This study indicates that mean blood flows <300 ml/min are not commonly associated with dialysis inadequacy. Setting a single blood flow cut point of <300 ml/min to define the need for intervention will result in a significant number of unnecessary interventions. There is a need to reexamine the definition of catheter dysfunction and expand the definition beyond blood flow rates.Clin C uffed, tunneled, dual-lumen central venous catheters (CVC) have become an acceptable form of hemodialysis (HD) vascular access when other permanent vascular accesses are unavailable, despite the associated high complication rates and mortality risk (1-4). In Canada, up to 70% of patients initiate HD with a CVC, and 33% continue to use catheters 90 days after dialysis initiation (5). This is far in excess of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) recommendation that CVC be used in Ͻ10% of prevalent HD patients (6).A common complication of the CVC is its inability to deliver adequate dialysis as a result of dysfunction. The definition of CVC dysfunction varies across the literature and includes variable rates of blood flow ranging from Ͻ100 to 350 ml/min (7-16). The NKF-DOQI vascular access guideline defines CVC dysfunction as failure to attain and maintain extracorporeal blood flow that is sufficient to perform HD without significantly lengthening the HD treatment and considered insufficient extracorporeal blood flow to be Ͻ300 ml/min (6). This recommendation was opinion based and has been interpreted as the need to maintain blood flows Ͼ300 ml/min to ensure adequate dialysis. As a result of these guidelines, CVC often are run in the reverse configuration, thrombolytic agents such as thromboplastin inhibitor (t-PA) are used, or catheters are rewired when blood flow is reduced to Ͻ300 ml/min. With the increase in CVC prevalence and the corresponding increase in thrombolytic use and subsequent cost consequences, there is a clear need to clarify the relationship between CVC blood flow a...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Relationship between Blood Flow in Central Venous Catheters and Hemodialysis Adequacy

Moist

Hemmelgarn

Lok

2006

Clinical Journal of the American Society of Nephrology

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“…A single instillation of low-dose alteplase with a 30-minute dwell restored or maintained Qb Ͼ300 without line reversals in 36 of 50 (72%) patients, with a second instillation restoring patency for a further four patients (40 of 50 patients; 80%) (59). The majority of patients (70%) required additional intervention within the 4-month follow-up of further alteplase instillation (62%; median time to next exposure 14 days) and/or radiologic intervention (59).…”

Section: Efficacy Of Lytic Therapy In Catheter Clearancementioning

confidence: 99%

“…Two studies have demonstrated efficacy for alteplase 1 mg/ml instillation in restoring the patency of occluded HD catheters (59,60). A single instillation of low-dose alteplase with a 30-minute dwell restored or maintained Qb Ͼ300 without line reversals in 36 of 50 (72%) patients, with a second instillation restoring patency for a further four patients (40 of 50 patients; 80%) (59).…”

Section: Efficacy Of Lytic Therapy In Catheter Clearancementioning

confidence: 99%

Catheter Management in Hemodialysis Patients

Besarab

Pandey²

2011

Clinical Journal of the American Society of Nephrology

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SummaryOver 330,000 individuals in the United States depend on hemodialysis (HD), the majority as a result of endstage renal disease. Sustainable vascular access can be achieved through arteriovenous fistulas, arteriovenous grafts, or tunneled catheters. Tunneled dialysis catheters (TDCs) often remain in use for months or even years, long beyond their initial intended use as a bridging device. Research efforts are focused on identifying strategies to prevent/minimize the risk of the most common catheter-related complications: thrombotic occlusion and infection. Thrombotic occlusion of TDCs prevents adequate dialysis but can be managed successfully through thrombolytic agents to restore/improve blood flow in the majority of patients, allowing immediate HD delivery and prolonging usability of the TDC. Occasionally, catheter exchange with fibrin sheath disruption is needed to preserve the site. Surface-treated catheters could improve the morbidity and mortality associated with HD delivery via an indwelling catheter, but results from studies have been disappointing to date. We review the etiology of catheter-based access failure and the monitoring and interventional steps that should be taken to maintain the patency and safety of catheters for HD. Wherever possible we note the areas in which there is scant data where further randomized clinical trials are needed.

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“…In fact, it is common to find a significant overall effect size in a meta‐analysis of studies that, as single studies, had no effect. In a prospective study that was characterized by a relatively small sample, Haymond et al . reported no difference between 1.0 and 2.0 mg tPA, and suggested that 1.0 mg tPA dose may be as efficacious as 2.0‐mg dose.…”

Section: Introductionmentioning

confidence: 99%

Comparison of alteplase (tissue plasminogen activator) high‐dose vs. low‐dose protocol in restoring hemodialysis catheter function: The ALTE‐DOSE study

Yaseen

El-Masri

Nekidy

et al. 2012

Hemodialysis International

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Hemodialysis catheter (HDC) dysfunction due to thrombosis is common, and dysfunction incidence can reach up to 50% within 1 year of use. Although administration of intraluminal alteplase (tissue plasminogen activator [tPA]) is the standard of practice to pharmacologically restore HDC function, there are no evidence-based guidelines concerning the optimal tPA dose. The purpose of this study was to compare the efficacy of 1.0-mg vs. 2.0-mg tPA dwell protocols in restoring the HDC function in thrombotic dysfunctional catheters. A retrospective, single-center study was conducted on two independent cohorts of patients; the first (n = 129) received 2.0 mg tPA/catheter lumen, while the second (n=108) received 1.0 mg tPA/catheter lumen. Kaplan-Meier and Cox regression analyses were performed to compare the catheter survival time between patients who received 1.0 mg tPA and those who received 2.0 mg tPA. Catheter removal occurred in 25 (19.4%) of those catheters treated with 1.0 mg tPA compared with 11 (10.2%) of catheters treated with 2.0 mg tPA (P = 0.05). The hazard ratio (HR) for catheter removal was 2.75 (95% confidence interval [(95%) CI] = 1.25-6.04) for the 1.0-mg tPA cohort compared with the 2.0-mg tPA cohort. Correction added on 3 December 2012, after first online publication: The tPA cohort values were changed. Female gender (HR = 2.51; (95%) CI = 1.20-5.27) and age (HR = 0.96; (95%) CI = 0.94-0.98) were also associated with catheter survival. Our findings suggest that treatment of dysfunctional HDC with 2.0-mg tPA dwells is superior to 1.0-mg tPA dwells.

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Efficacy of Low-Dose Alteplase for Treatment of Hemodialysis Catheter Occlusions

Abstract: Low dose alteplase 1 mg/lumen successfully treated occlusion of permanent hemodialysis catheters, with a resulting cost reduction.

Cited by 26 publications

References 14 publications

Relationship between Blood Flow in Central Venous Catheters and Hemodialysis Adequacy

Relationship between Blood Flow in Central Venous Catheters and Hemodialysis Adequacy

Catheter Management in Hemodialysis Patients

Comparison of alteplase (tissue plasminogen activator) high‐dose vs. low‐dose protocol in restoring hemodialysis catheter function: The ALTE‐DOSE study

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