Hemodialysis Catheters With Citrate Locking in Critically Ill Patients With Acute Kidney Injury Treated With Intermittent Online Hemofiltration or Hemodialysis

Abstract

The purpose of the study was to compare the long-term catheter-related complications associated with temporary untunneled hemodialysis catheters, locked with citrate in the interdialysis period, inserted in critically ill patients with acute kidney injury, between different catheter insertion sites (femoral vs. jugular and subclavian) and catheter types (single-lumen [SL] vs. double-lumen [DL]). In a retrospective clinical study, the long-term catheter-related complications in 290 critically ill patients treated with intermittent high-volume online hemofiltration or hemodialysis between December 2004 and January 2008 were analyzed. Among 534 inserted catheters, 493 (92.3%) were femoral, 29 (5.4%) jugular, and 12 (2.3%) subclavian; 304 (56.9%) were SL and 230 (43.1%) were DL. There were 125 (20.3/1000 catheter days [c.d.]) thrombotic complications, while infectious complications were exceptionally rare, that is, only 13 (2.1/1000 c.d.), of which 10 (1.6/1000 c.d.) were possible catheter-related bloodstream infections and 3 (0.5/1000 c.d.) exit-site infections. The incidence rate of all thrombotic complications was significantly lower in all jugular and subclavian vs. all femoral catheters (7.7/1000 c.d. vs. 21.8/1000 c.d., P = 0.01), and in all SL vs. DL catheters (11.4/1000 c.d. vs. 32.2/1000 c.d., P < 0.001). The incidence rate of any possible catheter-related bloodstream and exit-site infections was not significantly different in all jugular and subclavian vs. all femoral catheters, neither in femoral SL vs. DL catheters. The major long-term catheter-related complications were thrombotic, and significantly more frequent in DL vs. SL catheters. Infectious complications were exceptionally rare, most probably due to the strict catheter care protocol, as well as the routine use of a citrate catheter lock and antibiotic ointment at the catheter exit-site.

Quasi-Experimental Study of Sodium Citrate Locks and the Risk of Acute Hemodialysis Catheter Infection among Critically Ill Patients

“…The catheterization duration (7 days) reported in this study was similar to those reported in previous studies (5,8,(15)(16)(17)(18), ranging from 4.2 days (16) to 12.0 days (5). This short-term indwelling duration suggests that the extraluminal route of cathetertip colonization predominated (19).…”

“…However, the lower risk of catheter-tip colonization (38.7 versus 20.5 per 1,000 catheter-days) did not translate to a significantly lower risk of CRBSI (1.8 versus 1.1 per 1,000 catheter-days), possibly due to the low number of events expected with such a short indwell time. Our results support the concept of an antimicrobial catheter lock solution (14), specifically, a citrate solution, to prevent the risk of short-term catheter-associated infection risk among patients who require RRT in an ICU setting (5,8).…”

“…This study represented the third cohort (5,8) and largest comparison employing individual data to investigate the risk of dialysis catheter infection when using citrate locking in the ICU; thus, this cohort is unique. The findings are biologically plausible and supported by in vitro (22,28,37) and in vivo (31,35) studies.…”

How to deal with dialysis catheters in the ICU setting

“…In critically ill patients, there are numerous definitions of DC dysfunction, most of which apply to patients on intermittent hemodialysis [18-20]. In these studies, DC dysfunction is defined as the inability to attain and maintain blood flows of at least 150 ml/min [18], a low blood flow (<200 mL/min) incapable of providing adequate dialysis [19], and Q B reduction >20% despite attempts to restore patency [20]. In a recent study, DC dysfunction in patients on continuous RRT was defined by the necessity to replace the DC because of an inability to attain an adequate Q B through the DC [11].…”

Intermittent high-volume predilution on-line haemofiltration versus standard intermittent haemodialysis in critically ill patients with acute kidney injury: a prospective randomized study

“…Special protocol for regional citrate anticoagulation for HF was designed and successfully applied in patients with increased bleeding risk [32]. Temporary untunnelled HD catheters were used as vascular access in all study patients [33]. …”