Prevention of Dialysis Catheter Malfunction with Recombinant Tissue Plasminogen Activator

Hemmelgarn, Brenda R.; Moist, Louise; Lok, Charmaine E.; Tonelli, Marcello; Manns, Braden; Holden, Rachel M.; Leblanc, Martine; Faris, Peter; Barré, Paul E.; Zhang, Jianguo; Scott-Douglas, Nairne

doi:10.1056/nejmoa1011376

Cited by 185 publications

(131 citation statements)

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“…The risk for adverse events was similar (70% and 68.7%) in the rt-PA and heparin groups, respectively with no statistically significant difference in the serious adverse events between the two groups (20.9 % and 29.6%). Also, patients in the rt-PA group did not have a higher frequency and severity of bleeding episodes [5].…”

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confidence: 83%

“…Locking with heparin however, does not prevent bacterial colonization and subsequent development of CRBSI. Moreover, in vitro studies have shown that heparin may induce biofilm formation [4].Replacing heparin with recombinant tissue plasminogen activator (rt-PA) once a week, as a dialysis catheter locking solution significantly reduced the incidence of catheter malfunction and CRBSI in a well conducted multicenter, double-blind, randomized controlled trial from Canada by Hemmelgarn and colleagues [5]. The authors were able to decrease the rates of catheter malfunction by 50% and…”

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confidence: 99%

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confidence: 99%

“…Replacing heparin with recombinant tissue plasminogen activator (rt-PA) once a week, as a dialysis catheter locking solution significantly reduced the incidence of catheter malfunction and CRBSI in a well conducted multicenter, double-blind, randomized controlled trial from Canada by Hemmelgarn and colleagues [5]. The authors were able to decrease the rates of catheter malfunction by 50% and *Address correspondence to this author at the Nephrology Division, Department of Medicine, Al-Rahba hospital-Johns Hopkins Medicine International, PO Box 34555, Health Authority Abu Dhabi, Abu Dhabi, United Arab Emirates (UAE); Tel: (+971) 506370180; Fax: (+971) 2-5064000; E-mail: dranil_31982@yahoo.com CRBSI by two-thirds, with the use of rt-PA once a week at a dose 1 mg per lumen.…”

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confidence: 99%

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Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Saxena¹

2011

TOUNJ

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Arteriovenous fistulas (AVF) are the most preferred and promoted form of dialysis access due to their lowest complication rates. However, the changing demographic profile of end-stage renal disease (ESRD) with an increasing elderly and diabetic population having relatively poor vasculature, relative lack of prudent pre-ESRD planning for AV fistula creation, late referrals, and comparatively lower fistula maturation rates, are essentially the factors accountable for our continued dependence upon central venous catheters (CVCs) [1][2][3]. Moreover, CVCs remain the only means to provide instant access to the circulation during emergency situations arising from the unpredictable course of chronic kidney disease.Virchow's described three broad categories of factors that contribute to thrombus formation -hypercoagulability, stasis and vascular endothelial injury. The placement of this relatively large foreign body traumatizes the host vessel and significantly alters hemodynamics fulfilling Virchow's triad for thrombus formation and provides a nidus for bacterial entry into the circulation. However, catheter malfunction limits the life span of CVCs. Inadequate blood flow and catheter-related bloodstream infections (CRBSI) are common causes of recurrent use of thrombolytic therapy, antibiotics and often result in catheter removal. Generally, standard heparin (5000 U/ mL) is used to lock the CVCs to maintain catheter patency during the interdialytic period. Locking with heparin however, does not prevent bacterial colonization and subsequent development of CRBSI. Moreover, in vitro studies have shown that heparin may induce biofilm formation [4].Replacing heparin with recombinant tissue plasminogen activator (rt-PA) once a week, as a dialysis catheter locking solution significantly reduced the incidence of catheter malfunction and CRBSI in a well conducted multicenter, double-blind, randomized controlled trial from Canada by Hemmelgarn and colleagues [5]. The authors were able to decrease the rates of catheter malfunction by 50% and

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confidence: 83%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Saxena¹

2011

TOUNJ

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“…Thrombolytic locking solution has also shown promise in reducing bacteremias. The use of recombinant tissue plasminogen activator (rt-PA) substituting heparin at the midweek dialysis session significantly reduced the incidence of catheter malfunction and bacteremia [25] . When used for prevention, ALS significantly lowers CLABSI risk.…”

Section: Antimicrobial Lock Solutionsmentioning

confidence: 99%

Nosocomial Infections in Dialysis Access

Schweiger

Trevino²,

Marschall³

2015

Contributions to Nephrology

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Nosocomial infections in patients requiring renal replacement therapy have a high impact on morbidity and mortality. The most dangerous complication is bloodstream infection (BSI) associated with the vascular access, with a low BSI risk in arteriovenous fistulas or grafts and a comparatively high risk in central venous catheters. The single most important measure for preventing BSI is therefore the reduction of catheter use by means of early fistula formation. As this is not always feasible, prevention should focus on educational efforts, hand hygiene, surveillance of dialysis-associated events, and specific measures at and after the insertion of catheters. Core measures at the time of insertion include choosing the optimal site of insertion, the use of maximum sterile barrier precautions, adequate skin antisepsis, and the choice of catheter type; after insertion, access care needs to ensure hub disinfection and regular dressing changes. The application of antimicrobial locks is reserved for special situations. Evidence suggests that bundling a selection of the aforementioned measures can significantly reduce infection rates. The diagnosis of central lineassociated BSI (CLABSI) is based on clinical signs and microbiological findings in blood cultures ideally drawn both peripherally and from the catheter. The prompt installation of empiric antibiotic treatment covering the most commonly encountered organisms is key regarding CLABSI treatment. Catheter removal is recommended in complicated cases or if cultures yield Staphylococcus aureus , enterococci, Pseudomonas or fungi. In other cases, guide wire exchange or catheter salvage strategies with antibiotic lock solutions may be acceptable alternatives.

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Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults

López-Briz¹,

García

Cabello

et al. 2014

Cochrane Database of Systematic Reviews

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Prevention of Dialysis Catheter Malfunction with Recombinant Tissue Plasminogen Activator

Abstract: The use of rt-PA instead of heparin once weekly, as compared with the use of heparin three times a week, as a locking solution for central venous catheters significantly reduced the incidence of catheter malfunction and bacteremia. (Current Controlled Trials number, ISRCTN35253449.).

Cited by 185 publications

References 36 publications

Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Nosocomial Infections in Dialysis Access

Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults

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