Citrate versus heparin lock for prevention of hemodialysis catheter-related complications: updated systematic review and meta-analysis of randomized controlled trials

The use of Hub Devices to reduce catheter-related infections in dialysis patients: A narrative review

INTRODUCTION

Catheter-related bloodstream infections are among the most critical issues associated with central venous catheters used for dialysis treatment. To reduce the incidence of this life-threatening complication, various strategies have been developed. Among these, Hub Devices have been introduced in clinical practice to prevent microbial growth at the hub of the catheter.

METHODS

A review was conducted to assess the effectiveness of Hub Devices in reducing bloodstream infections in central venous catheters for dialysis, compared to solid caps. The review analyzed existing literature from three bibliographic databases (PubMed, Embase, and CINAHL) to provide evidence-based recommendations for clinical practice.

RESULTS

After a thorough review of the available data, it was found that out of the 873 records screened, only six trials met the inclusion criteria. Albeit the number of patients observed in these trials was more than 25,000, due to the differences in the mechanism of action of different Hub Devices and the lack of a standardized criterion to identify and measure the outcomes, it is difficult to draw a firm conclusion. It is worth noting, however, that in five out of six trials examined, the Hub Devices exhibited a protective effect when compared to solid caps.

CONCLUSIONS

The use of Hub Devices appears to be associated with a reduction in catheter-related bloodstream infections in the central venous catheter dialysis population. However, the Hub Devices show interesting results that should be investigated with further well-designed prospective studies.

Preventing adverse events during paediatric cancer treatment: protocol for a multi-site hybrid randomised controlled trial of catheter lock solutions (the CLOCK trial)

INTRODUCTION

Central venous access devices (CVADs) are commonly used for the treatment of paediatric cancer patients. Catheter locking is a routine intervention that prevents CVAD-associated adverse events, such as infection, occlusion and thrombosis. While laboratory and clinical data are promising, tetra-EDTA (T-EDTA) has yet to be rigorously evaluated or introduced in cancer care as a catheter lock.

METHODS AND ANALYSIS

This is a protocol for a two-arm, superiority type 1 hybrid effectiveness-implementation randomised controlled trial conducted at seven hospitals across Australia and New Zealand. Randomisation will be in a 3:2 ratio between the saline (heparinised saline and normal saline) and T-EDTA groups, with randomly varied blocks of size 10 or 20 and stratification by (1) healthcare facility; (2) CVAD type and (3) duration of dwell since insertion. Within the saline group, there will be a random allocation between normal and heparin saline. Participants can be re-recruited and randomised on insertion of a new CVAD. Primary outcome for effectiveness will be a composite of CVAD-associated bloodstream infections (CABSI), CVAD-associated thrombosis or CVAD occlusion during CVAD dwell or at removal. Secondary outcomes will include CABSI, CVAD-associated-thrombosis, CVAD failure, incidental asymptomatic CVAD-associated-thrombosis, other adverse events, health-related quality of life, healthcare costs and mortality. To achieve 90% power (alpha=0.05) for the primary outcome, data from 720 recruitments are required. A mixed-methods approach will be employed to explore implementation contexts from the perspective of clinicians and healthcare purchasers.

ETHICS AND DISSEMINATION

Ethics approval has been provided by Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (HREC/22/QCHQ/81744) and the University of Queensland HREC (2022/HE000196) with subsequent governance approval at all sites. Informed consent is required from the substitute decision-maker or legal guardian prior to participation. In addition, consent may also be obtained from mature minors, depending on the legislative requirements of the study site. The primary trial and substudies will be written by the investigators and published in peer-reviewed journals. The findings will also be disseminated through local health and clinical trial networks by investigators and presented at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622000499785.

Pediatric Central Venous Access Device Lock Solutions: A Network Meta-analysis

CONTEXT

Central venous access device (CVAD) locks are routine interventions used to prevent and treat complications, such as infection, thrombosis, and catheter occlusion.

OBJECTIVE

To compare and rank lock-solutions for prevention or treatment of complications in pediatrics. Design Systematic review and network meta-analysis.

DATA SOURCES

Five databases and 2 clinical trial registries were searched.

STUDY SELECTION

Published and unpublished randomized controlled trials that enrolled pediatric patients with a CVAD and compared the effectiveness of lock-solutions.

DATA EXTRACTION

Data extraction was conducted by 2 reviewers. Odds ratio (OR) for prevention or treatment of CVAD-associated bloodstream infection (BSI), thrombosis, occlusion, CVAD-failure, and mortality were calculated, with point estimates ranking lock-solutions.

RESULTS

Twenty-nine studies were included. Chelating agents and antibiotic locks given as prevention were associated with lower odds (OR: 0.11; 95% confidence interval [CI]: 0.02-0.67; moderate-quality; OR: 0.19; 95% CI: 0.05-0.79, high-quality, respectively) of CVAD-associated BSI compared with heparinized saline (reference). Preventative thrombolytic agents had lower odds (OR: 0.64, 95% CI: 0.44-0.93; low-quality) of CVAD occlusion, whereas ethanol had higher odds (OR: 2.84, 95% CI: 1.31-6.16; high-quality) compared with heparinized saline (reference). No lock solution had effects on thrombosis prevention or treatment, CVAD-failure, CVAD-associated BSI treatment failure, or mortality.

LIMITATIONS

There was substantial uncertainty around the point estimates because of the limited number of studies for outcomes and study heterogeneity. More high-quality studies are needed to confirm the efficacy of lock solutions.

CONCLUSIONS

Chelating agents and antibiotic locks may be effective for CVAD-associated BSI prevention in pediatrics. Thrombolytic agents can be an option for CVAD occlusion prevention, whereas ethanol may not be recommended.

Vancomycin and daptomycin stability in heparin or sodium citrate lock solutions

BACKGROUND

We investigated physical and chemical stability of daptomycin and vancomycin in heparin or sodium citrate lock solutions. The aim of this study was to find the optimal combination of antimicrobials and additives for lock solutions, which maximized patient safety.

METHODS

Vancomycin and daptomycin were diluted with heparin or sodium citrate to achieve final concentrations of vancomycin-heparin 2.5 mg/mL-833.33 U/mL, vancomycin-citrate 2.5-33.3 mg/mL, daptomycin-heparin 5 mg/mL-800 U/mL, and daptomycin-citrate 5-32 mg/mL and they were stored at room temperature (+25°C), 4°C, -20°C, and 37°C. Physical and chemical stability were analyzed for each antibiotic-anticoagulant combination in all conditions immediately after preparation, at 24, 48, 72 h and at different time points until unstable concentrations were obtained. Daptomycin-sodium citrate microbiological activity was also studied by evaluating two Staphylococcus aureus cultures in a calcium enriched medium with a daptomycin E test, with and without sodium citrate.

RESULTS

After incubation at 37°C vancomycin and daptomycin combined with heparin retained at least 90% of the initial concentration over 48 h. Vancomycin-sodium citrate solution stored at 37°C reduced more than 10% of the initial concentration at 24 h. On the other hand, daptomycin-sodium citrate preparation was stable at 37°C for 72 h but the microbiological activity of daptomycin was lower in the presence of sodium citrate.

CONCLUSIONS

The purpose is to prepare vancomycin and daptomycin lock solutions combined with heparin. They should be changed at 48 h and its stability is over 3 days at 25°C and 7 days at 4°C, which allow Hospital Pharmacy Services to manage their stocks. Daptomycin-sodium citrate combination is more stable for extended periods but its bioactivity has not been demonstrated.

Systematic review of locking solutions for non-tunneled hemodialysis catheters

BACKGROUND

We conducted a systematic review of studies investigating lock solutions for use in non-tunneled hemodialysis catheters.

METHODS

We searched PubMed and Cochrane databases from inception to June 11, 2021. Study inclusion criteria were: randomized trial or observational study, adults (>18 years), with acute kidney injury (AKI); and temporary non-tunneled catheters. We recorded bleeding events, catheter dysfunction and complications.

RESULTS

Of 649 studies identified, 6 were included (4 randomized, 1 non-randomized trial, 1 retrospective cohort study; sample sizes 78-1496 patients). Citrate was compared to heparin in 4 studies, to saline in 1, and ethanol versus saline in 1. Event-free survival of non-tunneled catheters did not differ between groups. Catheter-related infections and adverse events were less frequent with citrate locks, but reached statistical significance in only two studies.

CONCLUSION

Existing data are too heterogeneous to enable recommending one type of catheter lock over any other for non-tunneled hemodialysis catheters.

Meta-analysis of the efficacy of taurolidine in reducing catheter-related bloodstream infections for patients receiving parenteral nutrition

BACKGROUND

Parenteral nutrition administered via central venous catheter is an established treatment option for people with intestinal failure. A serious complication of central venous catheters is the high risk of catheter-related bloodstream infections (CRBSIs). Catheter-locking solutions are one strategy for CRBSI prevention, with the solution taurolidine showing beneficial effects. The aim of this meta-analysis was to identify and synthesize evidence to assess taurolidine efficacy against comparators for the prevention of CRBSI for people with intestinal failure receiving parenteral nutrition.

METHODS

Six health literature databases were searched for efficacy data of rate of CRBSI for taurolidine vs control among our study population; no study design limits were applied. Individual study data were presented for the number of CRBSIs and catheter days, and rate ratio. Overall data were synthesized as a pooled risk ratio, with subgroup analyses by study design, control type, and taurolidine solution.

RESULTS

Thirty-four studies were included in the final analysis. At the individual level, all studies showed superior efficacy of taurolidine vs control for prevention of CRBSIs. When the data were synthesized, the pooled risk ratio was 0.49 (95% CI, 0.46-0.53; P ≤ 0.0001), indicating a 51% decreased risk of CRBSI through the use of taurolidine. Subgroup analysis showed no difference depending on study design (P = 0.23) or control type (P = 0.37) and a significant difference for taurolidine type (P = 0.0005).

CONCLUSION

Taurolidine showed superior efficacy over controls regardless of study design or comparator group. The results show that taurolidine provides effective CRBSI reduction for people with intestinal failure receiving parenteral nutrition.

Hemostatic changes in patients undergoing hemodialysis: differences between central venous catheters and arterio-venous fistulas

BACKGROUND

Failure to mature the fistula in patients undergoing hemodialysis leads to prolonged use of the central venous catheter (CVC) and can compromise the patency of the catheter and the arteriovenous fistula (AVF) due to thrombus development.

OBJECTIVE

to evaluate hemostatic changes in patients undergoing hemodialysis with prolonged use of CVC or AVF.

METHOD

cross-sectional study with a total of 200 adult participants who were divided into the following groups: I:control; II: patients who had 5 to 8 months of CVC insertion; III: patients who had 9 to 36 months of insertion; IV patients who had 5 to 8 months of AVF and V: patients who had 9 to 36 months of AVF. Platelet activation was investigated by expressions of GPIIb/IIIa and p-selectin using flow cytometry. The Elisa-thrombomodulin test was used to compare groups III and V.

RESULTS

the p-selectin percentage expression of group I was 15.30 (12.30-16.80), II 23.25 (20.75-30.55) and III 54.00 (44.75 -59.29) were significant (p<0.001). Groups I, IV and V were also significant (p<0.001). The median fluorescence for GPIIb/IIIa for groups I, II and III were significant (p<0.0001). As for the Elisa test, an increased absorbance of thrombomodulin was verified in patients who used the CVC 4372 (3951-4733) when compared to those patients who used the AVF 2162 (1932-2485) (p<0.0001).

CONCLUSION

It can be concluded that CVC patients had a larger platelet expression of GPIIb/IIIa and p-selectin than AVF patients. The high concentration of thrombomodulin in CVC patients may suggest a greater stimulation of the intrinsic than extrinsic coagulation pathways.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

Heparin locks with low and high concentration in haemodialysis patients: A systematic review and meta-analysis

AIM

There is no evidence-based consensus on the optimal concentration for heparin locks; several randomized controlled trials (RCTs) have evaluated the concentration of heparin locks, yet the results remain inconsistent. We aimed to assess heparin locks with low and high concentration in haemodialysis patients.

METHODS

We performed a systematic review and meta-analysis of RCTs focusing on the concentration in heparin locks. Studies were identified by searching PUBMED, EMBASE, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI) and Wanfang databases (from inception to 15 March 2020). Summary risk ratios or mean differences with 95% confidence interval were calculated.

RESULTS

A total of 370 patients with four RCTs were included. Heparin locks with 1000 U/ml could significantly reduce the activated partial thromboplastin time (APTT) compared with 5000 U/ml. No significant differences were seen in the occurrence of catheter-related thrombosis, the length of catheter stay, the rates of bleeding and catheter occlusions between the two groups.

CONCLUSIONS

Lower concentrations in heparin lock are optimal for shortening APTT in haemodialysis patients; further studies are needed to elucidate the role of heparin concentration in the lock practice.

[The use of venous catheter : Which ones to choose, how to prevent their complications?]

Intravenous catheters are multiple and essential for daily practice. They are also responsible for high morbidity and mortality. Simple or echo-guided peripheral venous catheters, midlines, PICCline, tunneled or non-tunneled central venous catheters, and implantable venous access device are currently at our disposal. Thus, catheter selection, duration and indications for use, and prevention and treatment of complications vary according to the situation. The objective of this update is to provide the clinician with an overview of knowledge and rules of good practice on the use of catheters.