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Lazarus B, Kotwal S, Gallagher M, Gray NA, Coggan S, Rogers K, Talaulikar G, Polkinghorne KR. Effect of a Multifaceted Intervention on the Incidence of Hemodialysis Catheter Dysfunction in a National Stepped-Wedge Cluster Randomized Trial. Kidney Int Rep 2023; 8:1941-1950. [PMID: 37849996 PMCID: PMC10577327 DOI: 10.1016/j.ekir.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Effective strategies to prevent hemodialysis (HD) catheter dysfunction are lacking and there is wide variation in practice. Methods In this post hoc analysis of the REDUcing the burden of dialysis Catheter ComplicaTIOns: a national (REDUCCTION) stepped-wedge cluster randomized trial, encompassing 37 Australian nephrology services, 6361 participants, and 9872 catheters, we investigated whether the trial intervention, which promoted a suite of evidence-based practices for HD catheter insertion and management, reduced the incidence of catheter dysfunction, which is defined by catheter removal due to inadequate dialysis blood flow. We also analyzed outcomes among tunneled cuffed catheters and sources of event variability. Results A total of 873 HD catheters were removed because of dysfunction over 1.12 million catheter days. The raw incidence was 0.91 events per 1000 catheter days during the baseline phase and 0.68 events per 1000 catheter days during the intervention phase. The service-wide incidence of catheter dysfunction was 33% lower during the intervention after adjustment for calendar time (incidence rate ratio = 0.67; 95% confidence interval [CI], 0.50-0.89; P = 0.006). Results were consistent among tunneled cuffed catheters (adjusted incidence rate ratio = 0.68; 95% CI, 0.49-0.94), which accounted for 75% of catheters (n = 7403), 97.4% of catheter exposure time and 88.2% of events (n = 770). Among tunneled catheters that survived for 6 months (21.5% of tunneled catheters), between 2% and 5% of the unexplained variation in the number of catheter dysfunction events was attributable to service-level differences, and 18% to 36% was attributable to patient-level differences. Conclusion Multifaceted interventions that promote evidence-based catheter care may prevent dysfunction, and patient factors are an important source of variation in events.
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Affiliation(s)
- Benjamin Lazarus
- The George Institute for Global Health, UNSW, Sydney, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Sradha Kotwal
- The George Institute for Global Health, UNSW, Sydney, Australia
- Prince of Wales Hospital, UNSW Sydney, Australia
| | - Martin Gallagher
- The George Institute for Global Health, UNSW, Sydney, Australia
- South Western Sydney Campus, UNSW, Sydney, Australia
| | - Nicholas A. Gray
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Sarah Coggan
- The George Institute for Global Health, UNSW, Sydney, Australia
| | - Kris Rogers
- The George Institute for Global Health, UNSW, Sydney, Australia
- Graduate School of Health, The University of Technology Sydney, Sydney, Australia
| | - Girish Talaulikar
- Department of Nephrology, The Canberra Hospital, Garran, ACT, Australia
- Australian National University School of Medicine, Acton, ACT, Australia
| | - Kevan R. Polkinghorne
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, Australia
| | - REDUCCTION Investigators12
- The George Institute for Global Health, UNSW, Sydney, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
- Prince of Wales Hospital, UNSW Sydney, Australia
- South Western Sydney Campus, UNSW, Sydney, Australia
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Graduate School of Health, The University of Technology Sydney, Sydney, Australia
- Department of Nephrology, The Canberra Hospital, Garran, ACT, Australia
- Australian National University School of Medicine, Acton, ACT, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, Australia
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Caetano CP, Cassimiro VP, Dionisio DL, Pereira VP, Rodrigues EAC, Rosa PN, Elias DA, Ponce D. Topical gentamicin for the prevention of tunneled hemodialysis catheter-related infections: a randomized double-blind study. J Nephrol 2023; 36:1889-1896. [PMID: 37140818 DOI: 10.1007/s40620-023-01615-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/23/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Infection is the second leading cause of death in dialysis patients, with catheter-related bloodstream infection being the most serious. Exit Site Infection and Tunnel Infection are also related to the catheter. OBJECTIVE To compare the infection rates achieved with the application of either topical gentamicin or placebo to the exit-site of tunneled catheters filled with locking solution in chronic hemodialysis patients. METHODS This randomized double-blind clinical trial compared the application of 0.1% gentamicin versus placebo to the exit site of tunneled hemodialysis catheters filled with a prophylactic locking solution. A total of 91 patients were randomly allocated to 2 groups: placebo or 0.1% gentamicin. RESULTS Mean patient age was 60.4 (+ 15.3) years, with predominance of males (60.4%). The main cause of chronic kidney disease was diabetes (40.7%). The rates of exit site infection (placebo = 30% vs. gentamicin = 34.1%, p = 0.821), and bloodstream infection (placebo = 22% vs. gentamicin = 17.1%, p = 0.60), as well as both exit site infection and bloodstream infection incidence density per 1000 catheter-days (p = 1) did not differ between groups. The infection-free curve was also similar in both groups. CONCLUSION The application of topical 0.1% gentamicin to the exit site of tunneled catheters filled with lock solution did not reduce infectious complications when compared to topical placebo in patients on chronic hemodialysis.
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Affiliation(s)
- Camille Pereira Caetano
- UNESP FMB: Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Medicina Campus de Botucatu, Botucatu, São Paulo, Brazil.
| | - Vanessa Piacitelli Cassimiro
- UNESP FMB: Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Medicina Campus de Botucatu, Botucatu, São Paulo, Brazil
| | - Daniele Lopes Dionisio
- UNESP FMB: Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Medicina Campus de Botucatu, Botucatu, São Paulo, Brazil
| | - Viviane Pollo Pereira
- UNESP FMB: Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Medicina Campus de Botucatu, Botucatu, São Paulo, Brazil
| | | | - Priscila Nunes Rosa
- UNESP FMB: Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Medicina Campus de Botucatu, Botucatu, São Paulo, Brazil
| | - Daniele Aparecida Elias
- UNESP FMB: Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Medicina Campus de Botucatu, Botucatu, São Paulo, Brazil
| | - Daniela Ponce
- UNESP FMB: Universidade Estadual Paulista Julio de Mesquita Filho Faculdade de Medicina Campus de Botucatu, Botucatu, São Paulo, Brazil
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Vangala C, Shah M, Dave NN, Attar LA, Navaneethan SD, Ramanathan V, Crowley S, Winkelmayer WC. The landscape of renal replacement therapy in Veterans Affairs Medical Center intensive care units. Ren Fail 2021; 43:1146-1154. [PMID: 34261420 PMCID: PMC8280999 DOI: 10.1080/0886022x.2021.1949347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Outpatient dialysis is standardized with several evidence-based measures of adequacy and quality that providers aim to meet while providing treatment. By contrast, in the intensive care unit (ICU) there are different types of prolonged and continuous renal replacement therapies (PIRRT and CRRT, respectively) with varied strategies for addressing patient care and a dearth of nationally accepted quality parameters. To eventually describe appropriate quality measures for ICU-related renal replacement therapy (RRT), we first aimed to capture the variety and prevalence of basic strategies and equipment utilized in the ICUs of Veteran Affairs (VA) medical facilities with inpatient hemodialysis capabilities. Methods Via email to the dialysis directors of all VA facilities that provided inpatient hemodialysis during 2018, we requested survey participation regarding aspects of RRT in VA ICUs. Questions centered around the mode of therapy, equipment, solutions, prescription authority, nursing, anticoagulation, antimicrobial dosing, and access. Results Seventy-six centers completed the questionnaire, achieving a response rate of 87.4%. Fifty-five centers reported using PIRRT or CRRT in addition to intermittent hemodialysis. Of these centers, 42 reported being specifically CRRT-capable. Over half of respondents had the capabilities to perform PIRRT. Twelve centers (21.8%) were equipped to use slow low efficient dialysis (SLED) alone. Therapy was largely prescribed by nephrologists (94.4% of centers). Conclusions Within the VA system, ICU-related RRT practice is quite varied. Variation in processes of care, prescription authority, nursing care coordination, medication management, and safety practices present opportunities for developing cross-cutting measures of quality of intensive care RRT that are agnostic of modality choice.
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Affiliation(s)
- Chandan Vangala
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
| | - Maulin Shah
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Natasha N Dave
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | | | - Sankar D Navaneethan
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Venkat Ramanathan
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Susan Crowley
- Yale School of Medicine, New Haven, CT, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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Locked Away-Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis. J Clin Med 2021; 10:jcm10112230. [PMID: 34063913 PMCID: PMC8196553 DOI: 10.3390/jcm10112230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022] Open
Abstract
Reliable vascular access is necessary for effective hemodialysis. Guidelines recommend chronic hemodialysis via an arteriovenous fistula (AVF), however, in a significant number of patients, permanent central venous catheters (CVCs) are used. The use of a tunneled catheter is acceptable if the estimated dialysis time is less than a year or it is not possible to create an AVF. The main complications associated with CVC include thrombosis and catheter-related bloodstream infections (CRBSIs), which may result in loss of vascular access. The common practice is to use locking solutions to maintain catheter patency and minimize the risk of CRBSI. This paperwork summarizes information on currently available locking solutions for dialysis catheters along with their effectiveness in preventing thrombotic and infectious complications and describes methods of dealing with catheter dysfunction. The PubMed database was systematically searched for articles about locking solutions used in permanent CVCs in hemodialysis patients. Additional studies were identified by searching bibliographies and international guidelines. Articles on end-stage kidney disease patients dialyzed through a permanent CVC were included. Information from each primary study was extracted using pre-determined criteria including thrombotic and infectious complications of CVC use, focusing on permanent CVC if sufficient data were available. Of the currently available substances, it seems that citrate at a concentration of 4% has the best cost-effectiveness and safety profile, which is reflected in the international guidelines. Recent studies suggest the advantage of 2+1 protocols, i.e., taurolidine-based solutions with addition of urokinase once a week, although it needs to be confirmed by further research. Regardless of the type of locking solution, if prophylaxis with a thrombolytic agent is chosen, it should be started from the very beginning to reduce the risk of thrombotic complications. In case of CVC dysfunction, irrespective of the thrombolysis attempt, catheter replacement should be planned as soon as possible.
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Substitution of citrate with tissue plasminogen activator (rt-PA) for catheter lock does not improve patency of tunnelled haemodialysis catheters in a randomised trial. BMC Nephrol 2021; 22:41. [PMID: 33509107 PMCID: PMC7845091 DOI: 10.1186/s12882-021-02243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/14/2021] [Indexed: 11/10/2022] Open
Abstract
Backround The study aim was to establish if substitution of citrate with rt-PA for catheter lock once weekly can reduce the incidence of catheter-related blood stream infections (CR-BSI) or improve patency of tunneled haemodialysis catheters. Methods All incident patients undergoing insertion of a tunneled haemodialysis catheter were screened and included except those suffering infection or using oral anticoagulation. Study participants were randomized into two arms according to the solution applied as catheter lock: receiving either trisodium citrate (Citra-LockTM 4%) only or rt-PA (Actilyse® 1 mg/ml) on the middle session each week with citrate used on the first and third sessions. The incidence of CR-BSI (confirmed by positive blood culture), catheter non-function (complete obstruction), and malfunction (blood flow < 250 ml/min) was recorded. Statistical significance was tested with ANOVA, post hoc analysis was performed by means of multiple linear regression. Results Totally, 18 patients were included and followed during 655 haemodialysis sessions. No episode of CR-BSI was detected while 6 catheter non-functions (0.9% sessions) and 101 malfunctions (15.4% sessions) were recorded. The incidence of both events was equal between the study arms: 4 non-functions and 55 malfunctions in the rt-PA arm and 2 non-functions and 46 malfunctions in the citrate arm (p = 0.47 and p = 0.24, respectively). Additionally, the mean blood flow achieved did not differ significantly between the arms: 326 ± 1,8 and 326 ± 1,9 ml/min (p = 0.95) in rt-PA and citrate arms, respectively. Post hoc analysis identified time elapsed since previous session (β = 0.12, p = 0.005) and malfunction on previous session (β = 0.25, p < 0.001) as significant factors affecting the occurrence of malfunction. By contrast, the study arm, rt-PA application on previous session, and catheter vintage did not enter the model. Conclusion Substitution of citrate with rt-PA for catheter lock does not reduce the incidence of catheter malfunction neither does it affect the blood flow achieved during haemodialysis. Catheter patency is related rather to the time interval between sessions and to previous malfunction (thus probably reflecting undefined individual factors). The incidence of CR-BSI within pre-selected haemodialysis population is sporadic (less than 1 per 4.3 patient years in our sample). Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12612000152820. Retrospectively registered 03/02/2012.
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Tsujimoto H, Tsujimoto Y, Nakata Y, Fujii T, Takahashi S, Akazawa M, Kataoka Y. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2020; 12:CD012467. [PMID: 33314078 PMCID: PMC8812343 DOI: 10.1002/14651858.cd012467.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a major comorbidity in hospitalised patients. Patients with severe AKI require continuous renal replacement therapy (CRRT) when they are haemodynamically unstable. CRRT is prescribed assuming it is delivered over 24 hours. However, it is interrupted when the extracorporeal circuits clot and the replacement is required. The interruption may impair the solute clearance as it causes under dosing of CRRT. To prevent the circuit clotting, anticoagulation drugs are frequently used. OBJECTIVES To assess the benefits and harms of pharmacological interventions for preventing clotting in the extracorporeal circuits during CRRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials (RCTs or cluster RCTs) and quasi-RCTs of pharmacological interventions to prevent clotting of extracorporeal circuits during CRRT. DATA COLLECTION AND ANALYSIS Data were abstracted and assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) with 95% confidence intervals (CI). The primary review outcomes were major bleeding, successful prevention of clotting (no need of circuit change in the first 24 hours for any reason), and death. Evidence certainty was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS A total of 34 completed studies (1960 participants) were included in this review. We identified seven ongoing studies which we plan to assess in a future update of this review. No included studies were free from risk of bias. We rated 30 studies for performance bias and detection bias as high risk of bias. We rated 18 studies for random sequence generation,ÃÂ ÃÂ six studies for the allocation concealment, three studies for performance bias, three studies for detection bias,ÃÂ nine studies for attrition bias,ÃÂ 14 studies for selective reporting and nine studies for the other potential source of bias, as having low risk of bias. We identified eight studies (581 participants) that compared citrate with unfractionated heparin (UFH). Compared to UFH, citrate probably reduces major bleeding (RR 0.22, 95% CI 0.08 to 0.62; moderate certainty evidence) and probably increases successful prevention of clotting (RR 1.44, 95% CI 1.10 to 1.87; moderate certainty evidence). Citrate may have little or no effect on death at 28 days (RR 1.06, 95% CI 0.86 to 1.30, moderate certainty evidence). Citrate versus UFH may reduce the number of participants who drop out of treatment due to adverse events (RR 0.47, 95% CI 0.15 to 1.49; low certainty evidence). Compared to UFH, citrate may make little or no difference to the recovery of kidney function (RR 1.04, 95% CI 0.89 to 1.21; low certainty evidence). Compared to UFH, citrate may reduceÃÂ thrombocytopenia (RR 0.39, 95% CI 0.14 to 1.03; low certainty evidence). It was uncertain whether citrate reduces a cost to health care services because of inadequate data. For low molecular weight heparin (LMWH) versus UFH, six studies (250 participants) were identified. Compared to LMWH, UFH may reduce major bleeding (0.58, 95% CI 0.13 to 2.58; low certainty evidence). It is uncertain whether UFH versus LMWH reduces death at 28 days or leads to successful prevention of clotting. Compared to LMWH, UFH may reduce the number of patient dropouts from adverse events (RR 0.29, 95% CI 0.02 to 3.53; low certainty evidence). It was uncertain whether UFH versus LMWH leads to the recovery of kidney function because no included studies reported this outcome. It was uncertain whether UFH versus LMWH leads to thrombocytopenia. It was uncertain whether UFH reduces a cost to health care services because of inadequate data. For the comparison of UFH to no anticoagulation, one study (10 participants) was identified. It is uncertain whether UFH compare to no anticoagulation leads to more major bleeding. It is uncertain whether UFH improves successful prevention of clotting in the first 24 hours, death at 28 days, the number of patient dropouts due to adverse events, recovery of kidney function, thrombocytopenia, or cost to health care services because no study reported these outcomes. For the comparison ofÃÂ citrate to no anticoagulation,ÃÂ no completed study was identified. AUTHORS' CONCLUSIONS Currently,ÃÂ available evidence does not support the overall superiority of any anticoagulant to another. Compared to UFH, citrate probably reduces major bleeding and prevents clotting and probably has little or no effect on death at 28 days. For other pharmacological anticoagulation methods, there is no available data showing overall superiority to citrate or no pharmacological anticoagulation. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.
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Affiliation(s)
- Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Yasushi Tsujimoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukihiko Nakata
- Department of Mathematics, Shimane University, Matsue, Japan
| | - Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sei Takahashi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Mai Akazawa
- Department of Anesthesia, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Yuki Kataoka
- Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
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Tsujimoto H, Tsujimoto Y, Nakata Y, Fujii T, Takahashi S, Akazawa M, Kataoka Y. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2020; 3:CD012467. [PMID: 32164041 PMCID: PMC7067597 DOI: 10.1002/14651858.cd012467.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a major comorbidity in hospitalised patients. Patients with severe AKI require continuous renal replacement therapy (CRRT) when they are haemodynamically unstable. CRRT is prescribed assuming it is delivered over 24 hours. However, it is interrupted when the extracorporeal circuits clot and the replacement is required. The interruption may impair the solute clearance as it causes under dosing of CRRT. To prevent the circuit clotting, anticoagulation drugs are frequently used. OBJECTIVES To assess the benefits and harms of pharmacological interventions for preventing clotting in the extracorporeal circuits during CRRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials (RCTs or cluster RCTs) and quasi-RCTs of pharmacological interventions to prevent clotting of extracorporeal circuits during CRRT. DATA COLLECTION AND ANALYSIS Data were abstracted and assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) with 95% confidence intervals (CI). The primary review outcomes were major bleeding, successful prevention of clotting (no need of circuit change in the first 24 hours for any reason), and death. Evidence certainty was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS A total of 34 completed studies (1960 participants) were included in this review. We identified seven ongoing studies which we plan to assess in a future update of this review. No included studies were free from risk of bias. We rated 30 studies for performance bias and detection bias as high risk of bias. We rated 18 studies for random sequence generation, six studies for the allocation concealment, three studies for performance bias, three studies for detection bias, nine studies for attrition bias, 14 studies for selective reporting and nine studies for the other potential source of bias, as having low risk of bias. We identified eight studies (581 participants) that compared citrate with unfractionated heparin (UFH). Compared to UFH, citrate probably reduces major bleeding (RR 0.22, 95% CI 0.08 to 0.62; moderate certainty evidence). Citrate may have little or no effect on death at 28 days (RR 1.06, 95% CI 0.86 to 1.30, moderate certainty evidence), while citrate versus UFH may have little or no effect on successful prevention of clotting (RR 1.01, 95% CI 0.77 to 1.32; moderate certainty evidence). Citrate versus UFH may reduce the number of participants who drop out of treatment due to adverse events (RR 0.47, 95% CI 0.15 to 1.49; low certainty evidence). Compared to UFH, citrate may make little or no difference to the recovery of kidney function (RR 0.95, 95% CI 0.66 to 1.36; low certainty evidence). Compared to UFH, citrate may reduce thrombocytopenia (RR 0.39, 95% CI 0.14 to 1.03; low certainty evidence). It was uncertain whether citrate reduces a cost to health care services because of inadequate data. For low molecular weight heparin (LMWH) versus UFH, six studies (250 participants) were identified. Compared to LMWH, UFH may reduce major bleeding (0.58, 95% CI 0.13 to 2.58; low certainty evidence). It is uncertain whether UFH versus LMWH reduces death at 28 days or leads to successful prevention of clotting. Compared to LMWH, UFH may reduce the number of patient dropouts from adverse events (RR 0.29, 95% CI 0.02 to 3.53; low certainty evidence). It was uncertain whether UFH versus LMWH leads to the recovery of kidney function because no included studies reported this outcome. It was uncertain whether UFH versus LMWH leads to thrombocytopenia. It was uncertain whether UFH reduces a cost to health care services because of inadequate data. For the comparison of UFH to no anticoagulation, one study (10 participants) was identified. It is uncertain whether UFH compare to no anticoagulation leads to more major bleeding. It is uncertain whether UFH improves successful prevention of clotting in the first 24 hours, death at 28 days, the number of patient dropouts due to adverse events, recovery of kidney function, thrombocytopenia, or cost to health care services because no study reported these outcomes. For the comparison of citrate to no anticoagulation, no completed study was identified. AUTHORS' CONCLUSIONS Currently, available evidence does not support the overall superiority of any anticoagulant to another. Compared to UFH, citrate probably reduces major bleeding and probably has little or no effect on preventing clotting or death at 28 days. For other pharmacological anticoagulation methods, there is no available data showing overall superiority to citrate or no pharmacological anticoagulation. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.
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Affiliation(s)
- Hiraku Tsujimoto
- Hyogo Prefectural Amagasaki General Medical CenterHospital Care Research UnitHigashi‐Naniwa‐Cho 2‐17‐77AmagasakiHyogoHyogoJapan606‐8550
| | - Yasushi Tsujimoto
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yukihiko Nakata
- Shimane UniversityDepartment of Mathematics1060 Nishikawatsu choMatsue690‐8504Japan
| | - Tomoko Fujii
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMelbourneVICAustralia
| | - Sei Takahashi
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
- Fukushima Medical UniversityCenter for Innovative Research for Communities and Clinical Excellence (CiRC2LE)1 HikarigaokaFukushimaFukushimaJapan960‐1295
| | - Mai Akazawa
- Shiga University of Medical Science HospitalDepartment of AnesthesiaSeta‐Tsukinowa‐choOtsuShigaJapan520‐2192
| | - Yuki Kataoka
- Hyogo Prefectural Amagasaki General Medical CenterDepartment of Respiratory Medicine2‐17‐77, Higashi‐Naniwa‐ChoAmagasakiHyogoJapan660‐8550
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Sheng KX, Zhang P, Li JW, Cheng J, He YC, Böhlke M, Chen JH. Comparative efficacy and safety of lock solutions for the prevention of catheter-related complications including infectious and bleeding events in adult haemodialysis patients: a systematic review and network meta-analysis. Clin Microbiol Infect 2019; 26:545-552. [PMID: 31857208 DOI: 10.1016/j.cmi.2019.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/28/2019] [Accepted: 12/08/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Central venous catheters are used extensively as temporary or permanent vascular access for haemodialysis patients. Catheter-related bloodstream infections are the main complication of central venous catheters and increase morbidity and mortality in haemodialysis patients. OBJECTIVES The aim was to assess the most appropriate lock solution for central venous catheters to prevent catheter-related bloodstream infections and other complications. DATA SOURCES Medline, Embase and the Cochrane Central Register of Controlled Trials from the date of their inception to August 2018 were used as data sources. The reference lists of eligible studies and relevant reviews were also checked. STUDY ELIGIBILITY CRITERIA AND PARTICIPANTS Randomized controlled trials (RCTs) comparing different lock solutions for the prevention of central venous catheter-related infectious and bleeding complications for adult dialysis patients were included. INTERVENTIONS Interventions were lock solutions for haemodialysis catheters. METHODS The primary outcomes were catheter-related bloodstream infections and bleeding events. The secondary outcomes were catheter malfunction, exit-site infection, and all-cause mortality. We estimated summary risk ratios (RRs) using pairwise and network meta-analysis. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool. RESULTS Forty-nine trials (7020 patients) were included for this study. Compared with heparin 5000 U/mL, antibiotic locks (antibiotics with trisodium citrate (TSC), ethylenediamine tetraacetic acid (EDTA), heparin 5000 U/mL, low-dose heparin or urokinase) and ethanol locks were more effective in preventing catheter-related bloodstream infections. Antimicrobial agents plus low-dose heparin (500-2500 U/mL), TSC and low-dose heparin locks had lower risk of bleeding events than heparin 5000 U/mL. None of the lock solutions reduced rates of catheter malfunction and all-cause mortality compared with heparin 5000 U/mL. In summary, antibiotics plus low-dose heparin was ranked as the best lock solution. The overall results were not materially changed in sensitivity analyses. CONCLUSIONS Taking into account both efficacy and safety, antibiotics plus low-dose heparin (500-2500 U/mL) may be the preferred lock solution.
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Affiliation(s)
- K X Sheng
- Kidney Disease Centre, First Affiliated Hospital, College of Medicine, Zhejiang University; Key Laboratory of Kidney Disease Prevention and Control Technology, Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - P Zhang
- Kidney Disease Centre, First Affiliated Hospital, College of Medicine, Zhejiang University; Key Laboratory of Kidney Disease Prevention and Control Technology, Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - J W Li
- Kidney Disease Centre, First Affiliated Hospital, College of Medicine, Zhejiang University; Key Laboratory of Kidney Disease Prevention and Control Technology, Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - J Cheng
- Kidney Disease Centre, First Affiliated Hospital, College of Medicine, Zhejiang University; Key Laboratory of Kidney Disease Prevention and Control Technology, Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - Y C He
- Kidney Disease Centre, First Affiliated Hospital, College of Medicine, Zhejiang University; Key Laboratory of Kidney Disease Prevention and Control Technology, Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - M Böhlke
- Dialysis and Kidney Transplantation Unit, São Francisco de Paula University Hospital, Postgraduate Programme in Health and Behaviour, Catholic University of Pelotas, Pelotas, Brazil
| | - J H Chen
- Kidney Disease Centre, First Affiliated Hospital, College of Medicine, Zhejiang University; Key Laboratory of Kidney Disease Prevention and Control Technology, Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China.
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9
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Hemmelgarn BR, Manns BJ, Soroka SD, Levin A, MacRae J, Tennankore K, Wilson JAS, Weaver RG, Ravani P, Quinn RR, Tonelli M, Kiaii M, Mossop P, Scott-Douglas N. Effectiveness and Cost of Weekly Recombinant Tissue Plasminogen Activator Hemodialysis Catheter Locking Solution. Clin J Am Soc Nephrol 2018; 13:429-435. [PMID: 29335321 PMCID: PMC5967673 DOI: 10.2215/cjn.08510817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/28/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Evidence to guide hemodialysis catheter locking solutions is limited. We aimed to assess effectiveness and cost of recombinant tissue plasminogen activator (rt-PA) once per week as a locking solution, compared with thrice weekly citrate or heparin, in patients at high risk of complications. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used a prospective design and pre-post comparison in three sites across Canada. Pre-post comparisons were conducted using multilevel mixed effects regression models accounting for cluster with site and potential enrollment of patients more than once. In the pre period, catheter malfunction was managed as per site-specific standard of care. The intervention in the post period was once weekly rt-PA as a locking solution (with citrate or heparin used for other sessions). The primary outcome was rate of rt-PA use for treatment of catheter malfunction. Secondary outcomes included rates of bacteremia, management of catheter malfunction, and cost. RESULTS There were 374 patients (mean age 68 years; 52% men) corresponding to 506 enrollments. Mean length of enrollment was 200 days (SD 119) in the pre period and 187 days (SD 101) in the post period. There was a significant decline in rate of rt-PA use for treatment of catheter malfunction in the post compared with pre period (adjusted incidence rate ratio, 0.39; 95% confidence interval, 0.30 to 0.52); however, there was no difference in the rate of bacteremia, or catheter stripping or removal/replacement. The increase in mean total health care cost in the post period was CAD$962 per enrollment, largely related to costs of rt-PA as a locking solution. CONCLUSIONS Once weekly rt-PA as a catheter locking solution was associated with a reduction in rt-PA use for treatment of catheter malfunction. Our results showing a reduction in rescue rt-PA use are consistent with a prior randomized trial, although we did not observe a reduction in bacteremia or catheter stripping/removal and did observe an increased incremental cost of this strategy primarily accounted for by the cost of the rt-PA.
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Affiliation(s)
- Brenda R Hemmelgarn
- Department of Community Health Sciences and
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J Manns
- Department of Community Health Sciences and
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, Canada; and
| | - Jennifer MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Jo-Anne S Wilson
- Division of Nephrology, Department of Medicine, and
- Faculty of Health, College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert G Weaver
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Department of Community Health Sciences and
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert R Quinn
- Department of Community Health Sciences and
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Community Health Sciences and
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, Canada; and
| | - Paula Mossop
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Nairne Scott-Douglas
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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10
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Wei Y, Yang JW, Boddu SH, Jung R, Churchwell MD. Compatibility, Stability, and Efficacy of Vancomycin Combined With Gentamicin or Ethanol in Sodium Citrate as a Catheter Lock Solution. Hosp Pharm 2017; 52:685-690. [PMID: 29276240 DOI: 10.1177/0018578717726992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Indwelling catheters deliver lifesaving medical treatments for many chronically ill patients but are frequently a source of infection. Treatment may include an antimicrobial agent(s) and anticoagulant solution dwelling within the catheter. In vitro determinations of solution compatibility and stability are necessary prior to use in patients. Objective: The aim of this study was to determine the physical compatibility, chemical stability, and antimicrobial activity of vancomycin (5 or 10 mg/mL) with gentamicin (1 mg/mL) or 40% ethanol in 4% sodium citrate lock solution over 72 hours. Methods: All solutions were prepared per manufacturer's instructions. Samples were studied under 4 conditions: (1) 25°C with light, (2) 25°C without light, (3) 37°C with light, and (4) 37°C without light. Physical compatibility and chemical stability were assessed at 0, 24, 48, and 72 hours. Antimicrobial susceptibility testing was conducted at 0 and 72 hours. All studies were carried out in triplicate. Results: All solution combinations under each condition remained patent from baseline to 48 hours. One solution combination of vancomycin (5 mg/mL) and ethanol (40% v/v) in 4% sodium citrate revealed a slight turbidity at 72 hours. Clarity and pH remained stable in all other solutions during the entire study period. Chemical compatibility and antibiotic activity ranged from 95% to 105% and 95% to 106% of initial baseline values, respectively, for all solutions under 4 storage conditions. Conclusions: All antibiotic-anticoagulant lock solutions were found to be physically, chemically, and microbiologically stable during the 72-hour study period except vancomycin (5 mg/mL) and ethanol (40% v/v) in 4% sodium citrate solution which showed slight turbidity at 72 hours.
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11
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Moir D, Bodenham A. A narrative review of long-term central venous access devices for the intensivist. J Intensive Care Soc 2017; 19:236-246. [PMID: 30159016 DOI: 10.1177/1751143717741249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Long-term central venous access devices are increasingly prevalent and consequently often encountered by intensivists. This review introduces the different types of long-term central venous access devices, outlines their potential utility, examines potential complications associated with their use and outlines an approach to the management of these complications.
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Affiliation(s)
- David Moir
- Anaesthesia and Intensive Care Medicine, Leeds Teaching Hospital, Leeds, UK
| | - Andrew Bodenham
- Anaesthesia and Intensive Care Medicine, Leeds Teaching Hospital, Leeds, UK
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12
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Baumann Kreuziger L, Jaffray J, Carrier M. Epidemiology, diagnosis, prevention and treatment of catheter-related thrombosis in children and adults. Thromb Res 2017; 157:64-71. [DOI: 10.1016/j.thromres.2017.07.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 06/09/2017] [Accepted: 07/03/2017] [Indexed: 12/21/2022]
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13
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Tsujimoto H, Tsujimoto Y, Nakata Y, Fujii T, Akazawa M, Kataoka Y. Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hiraku Tsujimoto
- Hyogo Prefectural Amagasaki General Medical Center; Hospital Care Research Unit; Higashi-Naniwa-Cho 2-17-77 Amagasaki Hyogo Japan 606-8550
| | - Yasushi Tsujimoto
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
| | - Yukihiko Nakata
- Shimane University; Department of Mathematics; 1060 Nishikawatsu cho Matsue 690-8504 Japan
| | - Tomoko Fujii
- Graduate School of Medicine, Kyoto University; Department of Epidemiology and Preventive Medicine; Kyoto Japan
| | - Mai Akazawa
- Shiga University of Medical Science Hospital; Department of Anesthesia; Seta-Tsukinowa-cho Otsu Shiga Japan 520-2192
| | - Yuki Kataoka
- School of Public Health in the Graduate School of Medicine, Kyoto University; Department of Healthcare Epidemiology; Yoshida Konoe-cho, Sakyo-ku Kyoto Japan 606-8501
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14
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Abstract
Patients affected by cardiovascular disease (CVD) are treated with antiplatelet agents (AA) and/or anticoagulant drugs, which are fundamental in the management of stroke, coronary atherosclerotic disease, peripheral vascular disease and atrial fibrillation. CVD is the most important cause of death in chronic renal failure (CRF). Death rates from myocardial infarction (MI) and from all other cardiac causes exceed those for the general population. Incidence of MI in CRF is triple that in the general population. Moreover, mortality is seven- to eight-fold higher in patients requiring chronic hemodialysis compared to the general population, and approximately 40% of deaths in this population are attributable to coronary artery disease (CAD). For these reasons, AA are widely used in patients affected by CRF. Current data do not support a protective effect of antiplatelet administration in hemodialytic patients as primary prevention of cardiovascular mortality. Different results have been obtained concerning secondary prevention of CVD. The Cooperative Cardiovascular Project demonstrated that dialysis patients treated with aspirin following MI had a 43% lower mortality. Another study reported that the use of aspirin and beta-blockers following MI was associated with lower mortality in CRF patients. However, aspirin plus clopidogrel seems to increase the hemorrhagic risk without a significant reduction in cardiovascular mortality and there are insufficient data to support the use of new AA drugs in hemodialytic patients. In conclusion, since CRF patients are one of the groups at highest risk for atherosclerotic events, it could be reasonable to use aspirin in HD patients. However, the bleeding risk in HD patients needs to be strongly evaluated, especially before starting dual AA treatment.
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15
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Wang Y, Ivany JN, Perkovic V, Gallagher MP, Woodward M, Jardine MJ. Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end-stage kidney disease. Cochrane Database Syst Rev 2016; 4:CD009631. [PMID: 27039404 PMCID: PMC7097886 DOI: 10.1002/14651858.cd009631.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter-related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. OBJECTIVES This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter-related malfunction and sepsis in patients with end-stage kidney disease (ESKD). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. DATA COLLECTION AND ANALYSIS The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter-related bacteraemia, all-cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. MAIN RESULTS We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter-related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all-cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt-PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter-related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt-PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all-cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. AUTHORS' CONCLUSIONS The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter-related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta-analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed.
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Affiliation(s)
- Ying Wang
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionLevel 10, King George V Building83‐117 Missenden RdCamperdownNSWAustralia2050
| | - Jessica N Ivany
- Concord Repatriation General HospitalDepartment of Renal MedicineHospital RoadConcordNSWAustralia2139
| | - Vlado Perkovic
- The George Institute for Global Health, The University of SydneyLevel 10, King George V Building83‐117 Missenden RoadCamperdownNSWAustralia
| | - Martin P Gallagher
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionLevel 10, King George V Building83‐117 Missenden RdCamperdownNSWAustralia2050
- Concord Repatriation General HospitalDepartment of Renal MedicineHospital RoadConcordNSWAustralia2139
| | - Mark Woodward
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionLevel 10, King George V Building83‐117 Missenden RdCamperdownNSWAustralia2050
| | - Meg J Jardine
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionLevel 10, King George V Building83‐117 Missenden RdCamperdownNSWAustralia2050
- Concord Repatriation General HospitalDepartment of Renal MedicineHospital RoadConcordNSWAustralia2139
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