Vascular access‐related infection in nocturnal home hemodialysis

Abstract

Frequent hemodialysis is associated with increased vascular access adverse events. We hypothesized that bacteremia would be more frequent in patients with central venous catheter (CVC) than arteriovenous fistula or arteriovenous graft (AVF/AVG) in nocturnal home hemodialysis (NHHD). We reviewed blood culture reports and concurrent clinical data for a cohort of one hundred eighty-seven NHHD patients between January 1, 2006 and June 30, 2012. The primary outcome was time to first bacteremia, technique failure, or death after commencing NHHD. Types of bacteremia and clinical consequences were analyzed. Analyses were adjusted for a priori defined confounders. One hundred eighty-seven patients were included with a total follow up of six hundred five patient years. Initial vascular access was AVF in seventy-eight (42%) patients, AVG in eleven (6%) patients, and CVC in ninety-eight (52%) patients. A total of 79.3% of patients with a CVC reached the composite endpoint of bacteremia, technique failure, or death in the study period; 44.5% of patients with an AVF or AVG reached this composite endpoint. Adjusted time to first bacteremia, technique failure, or death was significantly shorter in patients with initial CVC access (hazard ratio 2.42, 95% confidence interval 1.50-3.90, p < 0.001). Risk factors for bacteremia were comorbid status quantified by the Charlson Comorbidity Index (p < 0.001) and diabetes (p < 0.001). Coagulase negative staphylococcus was the commonest organism cultured accounting for 51.4% bacteremias. The second commonest organism was staphylococcus aureus (20.3% bacteremias). Patients undergoing NHHD with a CVC have a shorter duration to first infection, technique failure, or death than those with permanent vascular access.

Association of Vascular Access Type with Mortality, Hospitalization, and Transfer to In-Center Hemodialysis in Patients Undergoing Home Hemodialysis

“…In patients undergoing in-center HD, use of CVCs is associated with greater risk of adverse clinical outcomes, including higher rates of mortality and hospitalization, at least in part because of greater incidence of infection-related complications (10)(11)(12)(13)(14). In contrast, there are only limited data examining the association of vascular access type with clinical outcomes for patients undergoing home HD, individuals in whom incidence of nosocomial infection may be lower (15).…”

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers

“…Patient choice has a significant role, especially in adolescents. Patients undergoing NHHD with a CVC have shown to have a decreased time to first infection, technique failure, or death than those with AVF/AVGs …”

Home hemodialysis associated infection—The “Achilles' Heel” of intensive hemodialysis

“…Infection‐related hospitalization rates range between 5.9 and 52.7 11–14 per 100 patient years. (Table ) Bacteremia rate ranges between 13 and 22 per 100 patient years …”

“…Use of CVC in HHD is associated with increased risk of mortality and hospitalization compared with AVF or AVG . (Table ) Initiation of HHD using a CVC is also associated with higher rate of bacteremia and shorter time to first bacteremia . Bacteremia rate is quoted to be 0.5 to 21.9 per 1000 patient days for catheters and less than 0.60 per 1000 patient days for permanent accesses including AVF and AVG .…”