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Celdran-Bonafonte D, Wang LH, Jarrouj A, Campos-Naciff B, Janda J, Roy-Chaudhury P. A pig model of tunneled dialysis catheter (TDC) infection and dysfunction: Opportunities for therapeutic innovation. J Vasc Access 2023; 24:674-682. [PMID: 34553619 DOI: 10.1177/11297298211046751] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although tunneled dialysis catheters (TDC) are far from ideal, they still represent the main form of vascular access for most patients beginning dialysis. Catheters are easy to place and allow patients instant access to dialysis, but regardless of these benefits, catheters are associated with a high incidence of significant complications like bloodstream infections, central venous stenosis, thrombosis, and dysfunction. In the present study, we aim to describe and characterize a swine model of catheter dysfunction and bloodstream infection, that recreates the clinical scenario, to help to serve as a platform to develop therapeutic innovations for this important clinical problem. METHODS Six Yorkshire cross pigs were used in this study. Non-coated commercial catheters were implanted in the external jugular recreating the main features of common clinical practice. Catheters were aseptically accessed twice a week for a mock dialysis procedure (flushing in and out) to assess for and identify catheter dysfunction. Animals were monitored daily for infections; once detected, blood samples were collected for bacterial culture and antibiograms. Study animals were euthanized when nonresponsive to treatment. Tissue samples were collected in a standardized fashion for macroscopic inspection and histological analysis. RESULTS The data analysis revealed an early onset of infection with a median time to infection of 9 days, 40% of the isolates were polymicrobial, and the average time to euthanasia was 20.16 ± 7.3 days. Median time to catheter dysfunction onset was 6 days post-implantation. Postmortem dissection revealed external fibrin sheath and internal thrombosis as the main causes of catheter dysfunction. There was also evidence of central venous stenosis with positive cells for αSMA, CD68, Ki67, Smoothelin, and Vimentin within the venous neointima. CONCLUSIONS The described model represents a reliable and reproducible large animal model of catheter dysfunction and bloodstream infection, which recreates all the main complications of TDC's and so could be used as a validated large animal model to develop new therapies for TDC related infection, thrombosis/dysfunction and central venous stenosis.
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Affiliation(s)
| | - Lihua H Wang
- Department of Kidney Disease and Blood Purification Centre, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Aous Jarrouj
- Trauma Surgery Division, Charleston Area Medical Center, Charleston, WV, USA
| | - Begona Campos-Naciff
- Division of Nephrology, Department of Internal Medicine, The University of Cincinnati, Cincinnati, OH, USA
| | - Jaroslav Janda
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Prabir Roy-Chaudhury
- UNC Kidney Center, Chapel Hill, NC, USA
- WG (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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2
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Wang L, Jia L, Jiang A. Pathology of catheter-related complications: what we need to know and what should be discovered. J Int Med Res 2022; 50:3000605221127890. [PMID: 36268763 PMCID: PMC9597033 DOI: 10.1177/03000605221127890] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite the considerable efforts made to increase the prevalence of autogenous fistula in patients on hemodialysis, tunneled cuffed catheters are still an important access modality and used in a high percentage of the hemodialysis population. However, because of the conundrum posed by tunneled cuffed catheters, patients can develop a multitude of complications, including thrombosis, infections, formation of a fibrin sheath, and central vein stenosis, resulting in increased morbidity and mortality as well as placing a heavy burden on the healthcare system. However, with an increasing number of studies now focusing on how to manage these catheter-related complications, there has been less translational research on the pathology of these complications. This review of the most recent literature provides an update on the pathological aspects of catheter-related complications, highlighting what we need to know and what is yet to be discovered. The future research strategies and innovations needed to prevent these complications are also addressed.
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Affiliation(s)
- Lihua Wang
- Lihua Wang, Department of Kidney Disease
and Blood Purification Centre, 2nd Hospital of Tianjin Medical University, 23rd
Pingjiang Road, Hexi District, Tianjin 300211, PR China.
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3
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Abstract
Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings. This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement. Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis. Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age). Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties. Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial. Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.
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4
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Onder AM, Cuff CF, Liang X, Billings AA, Onder S, Yu JJ, King JA. Detecting the prevalence of bacterial colonization on tunneled cuffed hemodialysis catheters using quantitative PCR targeting 16S rRNA and scanning electron microscopy. J Vasc Access 2021; 23:743-753. [PMID: 33855873 DOI: 10.1177/11297298211009016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Tunneled cuffed hemodialysis catheters (TCC) get colonized by microorganisms, increasing risk for catheter related bacteremia (CRB). Our objective was to detect the prevalence of bacterial colonization of TCC by using quantitative PCR (qPCR) targeting 16S rRNA and by determining the intraluminal adherent biological material (ABM) coverage. METHODS A total of 45 TCC were investigated. The 16S rRNA qPCR technique was used to detect bacterial colonization after scraping the intraluminal ABM. Proximal, middle, and distal TCC were evaluated by scanning electron microscopy (SEM) to determine the percentage (%) of intraluminal ABM coverage. All catheters were cultured following sonication. RESULTS A total of 45 TCC were removed: 7 due to CRB, 3 for suspected CRB and 35 were removed for non-infectious etiologies. Bacterial colonization was detected in 27 TCC by documenting 16S rRNA qPCR (+) results (60%). Seven of these 16S rRNA qPCR (+) catheters were removed due to CRB. There was no difference in demographic, clinical, or laboratory values between the 16S rRNA (+) versus (-) TCC. The 16S rRNA qPCR (-) outcome was highly associated with CRB-free status with negative predictive value of 100%. Bacterial colonization was documented in 10 TCC using catheter cultures (22%), which was significantly less compared to qPCR method (p = 0.0002). ABM were detected in all catheter pieces, with mean intraluminal surface coverage (ABMC) of 68.4 ± 26.1%. ABM was unlikely to be microbial biofilm in at least 36% of removed TCC as their 16S rRNA qPCR and catheter culture results were both negative. CONCLUSIONS Detecting bacterial colonization of TCC was significantly higher with 16S rRNA qPCR compared to catheter cultures. The 16S rRNA qPCR (-) cannot be predicted and was strongly associated with absence of CRB. Intraluminal ABM was not associated with microbial presence in about 1/3 of the TCC. These pieces of evidence may help to improve prophylactic strategies against CRB.
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Affiliation(s)
- Ali Mirza Onder
- Department of Pediatrics, West Virginia University, School of Medicine, Morgantown, WV, USA.,Division of Pediatric Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Christopher F Cuff
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Xiaobing Liang
- Department of Biochemistry, West Virginia University, School of Medicine, Morgantown, WV, USA
| | | | - Songul Onder
- Department of Medicine, West Virginia University, School of Medicine, Morgantown, WV, USA.,Department of Medicine, University of Tennessee, School of Medicine, Memphis, TN, USA
| | - Jing Jie Yu
- Department of Biochemistry, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Judy Ann King
- Department of Pathology, West Virginia University, School of Medicine, Morgantown, WV, USA.,Department of Pathology and Translational Pathobiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
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5
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Ielapi N, Nicoletti E, Lorè C, Guasticchi G, Avenoso T, Barbetta A, de Franciscis S, Andreucci M, Sapienza P, Serra R. The Role of Biofilm in Central Venous Catheter Related Bloodstream Infections: Evidence-based Nursing and Review of the Literature. Rev Recent Clin Trials 2021; 15:22-27. [PMID: 31656155 DOI: 10.2174/1574887114666191018144739] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/02/2019] [Accepted: 10/05/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Biofilm is a fundamental component in the pathogenesis of infections related to the use of the central venous catheter (CVC,) which can represent an important health issue in everyday practice of nursing and medical staff. OBJECTIVE The objective of the following review is to analyze the components of biofilm and their role in catheter-related infection determinism in an evidencebased nursing perspective in such a way as to give health professionals useful suggestions in the prevention and management of these complications. METHODS The following databases were consulted for the bibliographic search: Medline, Scopus, Science Direct. Biofilm can be the cause of CVC extraction and can lead to serious haematogenic infectious complications that can increase the morbidity and mortality of affected patients. RESULTS Updated pathophysiologic knowledge of biofilm formation and appropriate diagnostic methodology are pivotal in understanding and detecting CVC-related infections. Lock therapy appears to be a useful, preventive, and therapeutic aid in the management of CVCrelated infections. New therapies attempting to stop bacterial adhesion on the materials used could represent new frontiers for the prevention of CVC-related infections. CONCLUSION The correct evidence-based nursing methods, based on the use of guidelines, provides the opportunity to minimize the risks of infection through the implementation of a series of preventive measures both during the CVC positioning phase and in the subsequent phase, for example, during device management which is performed by medical and nursing staff.
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Affiliation(s)
- Nicola Ielapi
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Emergency, Vibo Valentia Hospital, Vibo Valentia (VV), Italy
| | | | | | - Giorgio Guasticchi
- Department of Medicine, Media Valle del Tevere Hospital, Todi (PG), Italy
| | - Tiziana Avenoso
- Department of Ophtalmology. Pugliese - Ciaccio - Hospital, Catanzaro (CZ), Italy
| | - Andrea Barbetta
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Michele Andreucci
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Paolo Sapienza
- Department of Surgery "Pietro Valdoni", "Sapienza" University of Rome, Rome, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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6
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Kuo TH, Lu CL, Chang YH, Li CY. Association of Dysfunction of Vascular Access for Hemodialysis With Major Adverse Cardiovascular Events - A Group-Based Trajectory Model Analysis. Circ J 2020; 84:1004-1011. [PMID: 32321881 DOI: 10.1253/circj.cj-19-1036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND An unconventional risk factor, "dysfunction of hemodialysis vascular access", was demonstrated to be associated with subsequent major adverse cardiovascular events (MACE) in our previous study. However, applying this suggestion in a clinical scenario may be not intuitive. A group-based trajectory model was applied to further recognize those patients with the highest risks for MACE.Methods and Results:In a cohort of patients who received hemodialysis from 2001 to 2010, we identified 9,711 cases that developed MACE in the stage of stable maintenance dialysis, and 19,422 randomly selected controls matched to cases on age, gender and duration of dialysis. Events of vascular access dysfunction in the 6-month period before MACE for cases and index dates for controls were evaluated. By group-based trajectory modeling, patients according to their counts of vascular access dysfunction in each month over the 6-month period prior to MACE or index dates were categorized. There were 26,744 patients in group 1 (no dysfunction), 650 in group 2 (escalating dysfunction) and 1,739 in group 3 (persistent dysfunction). Logistic regression analysis indicated that patients in group 3 had the highest chance of subsequent MACE (odds ratio 2.47, in comparison with group 1) after controlling for all the available potential confounders. CONCLUSIONS Uninterrupted clusters of vascular access dysfunction are associated with a higher risk of subsequent MACE.
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Affiliation(s)
- Te-Hui Kuo
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University.,Department of Public Health, College of Medicine, National Cheng Kung University
| | - Chin-Li Lu
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung Hsing University
| | - Ya-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University.,Department of Public Health, College of Public Health, China Medical University.,Department of Healthcare Administration, College of Medical and Health Science, Asia University
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7
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Tu YR, Tsai TY, Lin MS, Tu KH, Lee CC, Wu VCC, Hsu HH, Chang MY, Tian YC, Chang CH. Association between initial dialytic modalities and the risks of mortality, infection death, and cardiovascular events: A nationwide population-based cohort study. Sci Rep 2020; 10:8066. [PMID: 32415125 PMCID: PMC7229162 DOI: 10.1038/s41598-020-64986-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 04/24/2020] [Indexed: 11/20/2022] Open
Abstract
To date, few studies have been conducted to pairwise compare the prognosis of peritoneal dialysis (PD), unplanned PD, and unplanned hemodialysis (HD). We analyzed longitudinal data from Taiwan’s National Health Insurance Research Database. We included 45,165 patients whose initial dialytic modality was PD or unplanned HD between January 1, 2001 and December 31, 2013. We divided the patients into three groups according to their initial dialytic modalities. The primary outcomes were all-cause mortality and death from infection during 1-year follow up. The risks of all-cause mortality and infection death were higher in the unplanned PD group than in the planned PD group (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.28–1.60; HR 1.54, 95% CI 1.32–1.80). Likewise, the risks of all-cause mortality and infection death were higher in the unplanned HD group (HR 1.64, 95% CI 1.48–1.82; HR 1.85, 95% CI 1.61–2.13). Furthermore, the risks of all-cause mortality and infection death were also higher in the unplanned HD group than in the unplanned PD group (HR 1.15, 95% CI 1.07–1.23; HR 1.20, 95% CI 1.09–1.32). In conclusion, our study demonstrates that patients whose initial modality was planned PD or unplanned PD may have better clinical outcomes than those whose initial modality was unplanned HD.
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Affiliation(s)
- Yi-Ran Tu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsung-Yu Tsai
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shyan Lin
- Devision of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Yulin, Taiwan
| | - Kun-Hua Tu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | | | - Hsiang-Hao Hsu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Yang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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8
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Martin K, Lorenzo YSP, Leung PYM, Chung S, O'flaherty E, Barker N, Ierino F. Clinical Outcomes and Risk Factors for Tunneled Hemodialysis Catheter-Related Bloodstream Infections. Open Forum Infect Dis 2020; 7:ofaa117. [PMID: 32550235 PMCID: PMC7291682 DOI: 10.1093/ofid/ofaa117] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
Diabetes and left internal jugular vein insertion site were significantly associated with increased risk of a catheter-related bloodstream infection from a tunneled hemodialysis catheter. Ex-smoker status was significantly associated with reduced risk.
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Affiliation(s)
- Kylie Martin
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Yves S Poy Lorenzo
- Pharmacy Department, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,University of Melbourne, Melbourne Medical School, Department of Medicine, Fitzroy, Victoria, Australia
| | - Po Yee Mia Leung
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Sheri Chung
- Pharmacy Department, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Emmet O'flaherty
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Nuala Barker
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Francesco Ierino
- Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,University of Melbourne, Melbourne Medical School, Department of Medicine, Fitzroy, Victoria, Australia
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9
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Lin MY, Cheng LJ, Chiu YW, Hsieh HM, Wu PH, Lin YT, Wang SL, Jian FX, Hsu CC, Yang SA, Lee HL, Hwang SJ. Effect of national pre-ESRD care program on expenditures and mortality in incident dialysis patients: A population-based study. PLoS One 2018; 13:e0198387. [PMID: 29856821 PMCID: PMC5983494 DOI: 10.1371/journal.pone.0198387] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/17/2018] [Indexed: 12/01/2022] Open
Abstract
Inadequate care of chronic kidney disease (CKD) is common and may be associated with adverse outcomes after dialysis. The nationwide pre-end-stage renal disease pay for performance program (P4P) has been implemented in Taiwan to improve quality of CKD care. However, the effectiveness of the P4P program in improving the outcomes of pre-dialysis care and dialysis is uncertain. We conducted a longitudinal cohort study. Patients who newly underwent long-term dialysis (≥3 mo) between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. Based on the patient enrolment of the P4P program, they were categorized into P4P or non-P4P groups. We analysed pre-dialysis care, healthcare expenditures, and mortality between two groups. Among the 26 588 patients, 25.5% participated in the P4P program. The P4P group received significantly better quality of care, including a higher frequency of glomerular filtration rate measurement and CKD complications survey, a higher rate of vascular access preparation, and more frequent use of arteriovenous fistulas than the non-P4P group did. The P4P group had a 68.4% reduction of the 4-year total healthcare expenditure (excluding dialysis fee), which is equivalent to US$345.7 million, and a significant 22% reduction in three-year mortality after dialysis (hazard ratio 0.78, 95% confidence interval: 0.75–0.82, P < 0.001) compared with the non-P4P group. P4P program improves quality of pre-dialysis CKD care, and provide survival benefit and a long-term cost saving for dialysis patients.
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Affiliation(s)
- Ming-Yen Lin
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Jen Cheng
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Min Hsieh
- Department of Public Health, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Hsun Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Li Wang
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Xuan Jian
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- Department of Health Services Administration, China Medical University, Taichung City, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shu-An Yang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huei-Lan Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- * E-mail:
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10
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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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Ravani P, Quinn R, Oliver M, Robinson B, Pisoni R, Pannu N, MacRae J, Manns B, Hemmelgarn B, James M, Tonelli M, Gillespie B. Examining the Association between Hemodialysis Access Type and Mortality: The Role of Access Complications. Clin J Am Soc Nephrol 2017; 12:955-964. [PMID: 28522650 PMCID: PMC5460718 DOI: 10.2215/cjn.12181116] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/24/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES People receiving hemodialysis to treat kidney failure need a vascular access (a fistula, a graft, or a central venous catheter) to connect to the blood purification machine. Higher rates of access complications are considered the mechanism responsible for the excess mortality observed among catheter or graft users versus fistula users. We tested this hypothesis using mediation analysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied incident patients who started hemodialysis therapy from North America, Europe, and Australasia (the Dialysis Outcomes and Practice Patterns Study; 1996-2011). We evaluated the association between access type and time to noninfectious (e.g., thrombosis) and infectious complications of the access (mediator model) and the relationship between access type and time-dependent access complications with 6-month mortality from the creation of the first permanent access (outcome model). In mediation analysis, we formally tested whether access complications explain the association between access type and mortality. RESULTS Of the 6119 adults that we studied (mean age =64 [SD=15] years old; 58% men; 47% patients with diabetes), 50% had a permanent catheter for vascular access, 37% had a fistula, and 13% had a graft. During the 6-month study follow-up, 2084 participants (34%) developed a noninfectious complication of the access, 542 (8.9%) developed an infectious complication, and 526 (8.6%) died. Access type predicted the occurrence of access complications; both access type and complications predicted mortality. The associations between access type and mortality were nearly identical in models excluding and including access complications (hazard ratio, 2.00; 95% confidence interval, 1.55 to 2.58 versus hazard ratio, 2.01; 95% confidence interval, 1.56 to 2.59 for catheter versus fistula, respectively). In mediation analysis, higher mortality with catheters or grafts versus fistulas was not the result of increased rates of access complications. CONCLUSIONS Hemodialysis access complications do not seem to explain the association between access type and mortality. Clinical trials are needed to clarify whether these associations are causal or reflect confounding by underlying disease severity.
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Affiliation(s)
- Pietro Ravani
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Quinn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Neesh Pannu
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada; and
| | - Jennifer MacRae
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden Manns
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew James
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
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Clark E, Kappel J, MacRae J, Dipchand C, Hiremath S, Kiaii M, Lok C, Moist L, Oliver M, Miller LM. Practical Aspects of Nontunneled and Tunneled Hemodialysis Catheters. Can J Kidney Health Dis 2016; 3:2054358116669128. [PMID: 28270920 PMCID: PMC5332079 DOI: 10.1177/2054358116669128] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 12/20/2022] Open
Abstract
Nontunneled hemodialysis catheters (NTHCs) are typically used when vascular access is required for urgent renal replacement therapy. The preferred site for NTHC insertion in acute kidney injury is the right internal jugular vein followed by the femoral vein. When aided by real-time ultrasound, mechanical complications related to NTHC insertion are significantly reduced. The preferred site for tunneled hemodialysis catheters placement is the right internal jugular vein followed by the left internal jugular vein. Ideally, the catheter should be inserted on the opposite side of a maturing or planned fistula/graft. Several dual-lumen, large-diameter catheters are available with multiple catheter tip designs, but no one catheter has shown significant superior performance.
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Affiliation(s)
- Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Jennifer MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | | | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Peptide-Mediated PEGylation of Polysulfone Reduces Protein Adsorption and Leukocyte Activation. ASAIO J 2016; 61:710-7. [PMID: 26181712 DOI: 10.1097/mat.0000000000000265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The exposure of blood to bioincompatible materials used for dialysis triggers leukocyte activation and protein adsorption. We describe a single-step, postmanufacturing method for surface modification to create biomaterials used in medical devices and dialysis with altered surface characteristics. Peptides derived from the receptor-binding domain of the type IV pilin of Pseudomonas aeruginosa were synthesized using L and D-amino acids to generate L-K122-4, enantiomer D-K122-4, and D-retroinverso RI-K122-4 peptides. L-K122-4, D-K122-4, and RI-K122-4 peptides, but not control peptides, bound durably to the surfaces of materials used in medical devices and dialysis including silicone and polysulfone. D-K122-4 enantiomeric peptides were protease resistant on polysulfone and could remain bound to the surface for up to 28 days. To demonstrate that K122-4 peptides could be used to modify material surfaces, D-K122-4 peptide was conjugated to polyethylene glycol (D-K122-4-PEG) and applied to polysulfone. When compared with untreated material, D-K122-4-PEG reduced the surface adsorption of albumin or immunoglobulin G to polysulfone. In coincubation experiments, although uncoated polysulfone induced pro-interleukin-1β cytokine expression in leukocytes, cellular activation was prevented when leukocytes were incubated with D-K122-4-PEG-modified polysulfone. These data demonstrate the proof of principle that K122-4 peptides can be applied to modify the surface characteristics of materials used for dialysis.
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Deciphering the Contribution of Biofilm to the Pathogenesis of Peritoneal Dialysis Infections: Characterization and Microbial Behaviour on Dialysis Fluids. PLoS One 2016; 11:e0157870. [PMID: 27336367 PMCID: PMC4918928 DOI: 10.1371/journal.pone.0157870] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/06/2016] [Indexed: 12/20/2022] Open
Abstract
Infections are major complications in peritoneal dialysis (PD) with a multifactorial etiology that comprises patient, microbial and dialytic factors. This study aimed at investigating the contribution of microbial biofilms on PD catheters to recalcitrant infections and their interplay with PD related-factors. A prospective observational study was performed on 47 patients attending Centro Hospitalar of Porto and Vila Nova de Gaia/Espinho to whom the catheter was removed due to infectious (n = 16) and non-infectious causes (n = 31). Microbial density on the catheter was assessed by culture methods and the isolated microorganisms identified by matrix-assisted laser desorption/ionization time-of-flight intact cell mass spectrometry. The effect of conventional and three biocompatible PD solutions on 16 Coagulase Negative Staphylococci (CNS) and 10 Pseudomonas aeruginosa strains planktonic growth and biofilm formation was evaluated. Cultures were positive in 87.5% of the catheters removed due infectious and 90.3% removed due to non-infectious causes. However, microbial yields were higher on the cuffs of catheters removed due to infection vs. non-infection. Staphylococci (CNS and Staphylococcus aureus) and P. aeruginosa were the predominant species: 32% and 20% in the infection and 43.3% and 22.7% in the non-infection group, respectively. In general, PD solutions had a detrimental effect on planktonic CNS and P. aeruginosa strains growth. All strains formed biofilms in the presence of PD solutions. The solutions had a more detrimental effect on P. aeruginosa than CNS strains. No major differences were observed between conventional and biocompatible solutions, although in icodextrin solution biofilm biomass was lower than in bicarbonate/lactate solution. Overall, we show that microbial biofilm is universal in PD catheters with the subclinical menace of Staphylococci and P. aeruginosa. Cuffs colonization may significantly contribute to infection. PD solutions differentially impact microbial species. This knowledge is important for the development of infection diagnosis, treatment and preventive strategies.
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Polkinghorne KR. How Can the Complications of Central Vein Catheters Be Reduced?: Intraluminal Prophylaxis and Management of Catheter Infections: Role of Antibiotic Locks. Semin Dial 2016; 29:197-8. [PMID: 26875584 DOI: 10.1111/sdi.12476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Clayton, Melbourne, Australia.,Department of Medicine, Monash University, Clayton, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Melbourne, Australia
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Kuo TH, Tseng CT, Lin WH, Chao JY, Wang WM, Li CY, Wang MC. Association Between Vascular Access Dysfunction and Subsequent Major Adverse Cardiovascular Events in Patients on Hemodialysis: A Population-Based Nested Case-Control Study. Medicine (Baltimore) 2015; 94:e1032. [PMID: 26131808 PMCID: PMC4504615 DOI: 10.1097/md.0000000000001032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The association between dialysis vascular access dysfunction and the risk of developing major adverse cardiovascular events (MACE) in hemodialysis patients is unclear and has not yet been investigated. We analyzed data from the National Health Insurance Research Database of Taiwan to quantify this association. Adopting a case-control design nested within a cohort of patients who received hemodialysis from 2001 to 2010, we identified 9711 incident cases of MACE during the stage of stable maintenance dialysis and 19,422 randomly selected controls matched to cases on age, gender, and duration of dialysis. Events of vascular access dysfunction in the 6-month period before the date of MACE onset (ie, index date) for cases and before index dates for controls were evaluated retrospectively. The presence of vascular access dysfunction was associated with a 1.385-fold higher odds of developing MACE as estimated from the logistic regression analysis. This represents a significantly increased adjusted odds ratio (OR) at 1.268 (95% confidence interval [CI] = 1.186-1.355) after adjustment for comorbidities and calendar years of initiating dialysis. We also noted a significant exposure-response trend (P < 0.001) between the frequency of vascular access dysfunction and MACE, with the greatest risk (adjusted OR = 1.840, 95% CI = 1.549-2.186) noted in patients with ≥3 vascular access events. We concluded that dialysis vascular access dysfunction was significantly associated with an increased risk of MACE. Hence, vascular access failure can be an early sign for MACE in patients receiving maintenance hemodialysis. Active monitoring and treatment of cardiovascular risk factors and related diseases, not merely managing vascular access dysfunction, would be required to reduce the risk of MACE.
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Affiliation(s)
- Te-Hui Kuo
- From the Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (T-HK, M-CW); Department and Graduate Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan (T-HK, C-YL); Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan (T-HK, C-TT, J-YC); Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (W-HL); Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan (W-HL); Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan (J-YC, M-CW); Biostatistics Consulting Center, College of Medicine, National Cheng Kung University, Tainan, Taiwan (W-MW); and Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan (C-YL)
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Brañas P, Morales E, Ríos F, Sanz F, Gutiérrez E, Quintanilla N, Orellana MA, Sánchez M, Rodríguez-Aranda A, Chaves F. Usefulness of endoluminal catheter colonization surveillance cultures to reduce catheter-related bloodstream infections in hemodialysis. Am J Infect Control 2014; 42:1182-7. [PMID: 25248485 DOI: 10.1016/j.ajic.2014.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/21/2014] [Accepted: 07/21/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND To evaluate the use of surveillance cultures (SCs) to prevent catheter-related bloodstream infections (CRBSIs) in asymptomatic hemodialysis (HD) patients. METHODS In 2011-2012, we conducted a prospective study of HD patients with tunneled cuffed central venous catheters (TCCs). Colonization of the catheter lumen was assessed every 15 days by inoculating ~5 mL endoluminal blood into aerobic culture bottles. Individual patients were triaged based on SC results: group 1 (negative); group 2 (coagulase-negative Staphylococcus [CoNS] with time-to-positivity (TTP) >14 hours); group 3 (CoNS with TTP ≤14 hours); and group 4 (any microorganism other than CoNS and any TTP). RESULTS We studied 104 patients (129 TCCs). Median follow-up was 262.5 days (interquartile range [IR], 135.0-365.0). A total of 1,734 SCs were collected (median, 18 per patient; IR, 10.0-24.0), of which 1,634 (94.2%) were negative (group 1) and 100 (5.8%) were positive (group 2: 79; group 3: 12, group 4: 9). In groups 2 and 3, 19 TCCs required antibiotic lock therapy (ALT). In group 4, all patients received intravenous therapy and ALT. Under this protocol, there were 0.27 episodes of CRBSI per 1,000 catheter days compared with 1.65 (P < .001) prior to its implementation. CONCLUSION SCs based on easily accessible samples proved useful in triaging HD patients at a high risk of infection.
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18
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What is the evidence for intraluminal colonization of hemodialysis catheters? Kidney Int 2014; 86:28-33. [DOI: 10.1038/ki.2013.527] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 09/13/2013] [Accepted: 09/19/2013] [Indexed: 12/14/2022]
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Gauna TT, Oshiro E, Luzio YC, Paniago AMM, Pontes ERJC, Chang MR. Bloodstream infection in patients with end-stage renal disease in a teaching hospital in central-western Brazil. Rev Soc Bras Med Trop 2014; 46:426-32. [PMID: 23970309 DOI: 10.1590/0037-8682-0060-2013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 07/10/2013] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Vascular access in patients undergoing hemodialysis is considered a critical determinant of bloodstream infection (BSI) and is associated with high morbidity and mortality. The purpose of this study was to investigate the occurrence of BSI in patients with end-stage renal disease using central venous catheters for hemodialysis. METHODS A cohort study was conducted in a public teaching hospital in central-western Brazil from April 2010 to December 2011. For every patient, we noted the presence of hyperemia/exudation upon catheter insertion, as well as fever, shivering, and chills during hemodialysis. RESULTS Fifty-nine patients were evaluated. Thirty-fi ve (59.3%) patients started dialysis due to urgency, 37 (62.7%) had BSI, and 12 (20%) died. Hyperemia at the catheter insertion site (64.9%) was a significant clinical manifestation in patients with BSI. Statistical analysis revealed 1.7 times more cases of BSI in patients with hypoalbuminemia compared with patients with normal albumin levels. The principal infective agents identified in blood cultures and catheter-tip cultures were Staphylococcus species (24 cases), non-fermentative Gram-negative bacilli (7 cases of Stenotrophomonas maltophilia and 5 cases of Chryseobacterium indologenes), and Candida species (6). Among the Staphylococci identified, 77.7% were methicillin-resistant, coagulase-negative Staphylococci. Of the bacteria isolated, the most resistant were Chryseobacterium indologenes and Acinetobacter baumannii. CONCLUSIONS Blood culture was demonstrated to be an important diagnostic test and identified over 50% of positive BSI cases. The high frequency of BSI and the isolation of multiresistant bacteria were disturbing findings. Staphylococcus aureus was the most frequently isolated microorganism, although Gram-negative bacteria predominated overall. These results highlight the importance of infection prevention and control measures in dialysis units.
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Affiliation(s)
- Tamara Trelha Gauna
- Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Groso do Sul, Campo Grande, MS.
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Ramanathan V, Darouiche RO. Prevention and management of hemodialysis catheter infections. Expert Rev Anti Infect Ther 2014; 10:1447-55. [DOI: 10.1586/eri.12.134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ravani P, Gillespie BW, Quinn RR, MacRae J, Manns B, Mendelssohn D, Tonelli M, Hemmelgarn B, James M, Pannu N, Robinson BM, Zhang X, Pisoni R. Temporal risk profile for infectious and noninfectious complications of hemodialysis access. J Am Soc Nephrol 2013; 24:1668-77. [PMID: 23847278 DOI: 10.1681/asn.2012121234] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Vascular access complications are a major cause of morbidity in patients undergoing hemodialysis, and determining how the risks of different complications vary over the life of an access may benefit the design of prevention strategies. We used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to assess the temporal profiles of risks for infectious and noninfectious complications of fistulas, grafts, and tunneled catheters in incident hemodialysis patients. We used longitudinal data to model time from access placement or successful treatment of a previous complication to subsequent complication and considered multiple accesses per patient and repeated access complications using baseline and time-varying covariates to obtain adjusted estimates. Of the 7769 incident patients identified, 7140 received at least one permanent access. During a median follow-up of 14 months (interquartile range, 7-22 months), 10,452 noninfectious and 1131 infectious events (including 551 hospitalizations for sepsis) occurred in 112,085 patient-months. The hazards for both complication types declined over time in all access types: They were 5-10 times greater in the first 3-6 months than in later periods after access placement or a remedial access-related procedure. The hazards declined more quickly with fistulas than with grafts and catheters (P<0.001; Weibull regression). These data indicate that risks for noninfectious and infectious complications of the hemodialysis access decline over time with all access types and suggest that prevention strategies should target the first 6 months after access placement or a remedial access-related procedure.
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Ravani P, Palmer SC, Oliver MJ, Quinn RR, MacRae JM, Tai DJ, Pannu NI, Thomas C, Hemmelgarn BR, Craig JC, Manns B, Tonelli M, Strippoli GFM, James MT. Associations between hemodialysis access type and clinical outcomes: a systematic review. J Am Soc Nephrol 2013; 24:465-73. [PMID: 23431075 DOI: 10.1681/asn.2012070643] [Citation(s) in RCA: 465] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Clinical practice guidelines recommend an arteriovenous fistula as the preferred vascular access for hemodialysis, but quantitative associations between vascular access type and various clinical outcomes remain controversial. We performed a systematic review of cohort studies to evaluate the associations between type of vascular access (arteriovenous fistula, arteriovenous graft, and central venous catheter) and risk for death, infection, and major cardiovascular events. We searched MEDLINE, EMBASE, and article reference lists and extracted data describing study design, participants, vascular access type, clinical outcomes, and risk for bias. We identified 3965 citations, of which 67 (62 cohort studies comprising 586,337 participants) met our inclusion criteria. In a random effects meta-analysis, compared with persons with fistulas, those individuals using catheters had higher risks for all-cause mortality (risk ratio=1.53, 95% CI=1.41-1.67), fatal infections (2.12, 1.79-2.52), and cardiovascular events (1.38, 1.24-1.54). Similarly, compared with persons with grafts, those individuals using catheters had higher risks for mortality (1.38, 1.25-1.52), fatal infections (1.49, 1.15-1.93), and cardiovascular events (1.26, 1.11-1.43). Compared with persons with fistulas, those individuals with grafts had increased all-cause mortality (1.18, 1.09-1.27) and fatal infection (1.36, 1.17-1.58), but we did not detect a difference in the risk for cardiovascular events (1.07, 0.95-1.21). The risk for bias, especially selection bias, was high. In conclusion, persons using catheters for hemodialysis seem to have the highest risks for death, infections, and cardiovascular events compared with other vascular access types, and patients with usable fistulas have the lowest risk.
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Affiliation(s)
- Pietro Ravani
- University of Calgary, Faculty of Medicine, Department of Medicine, Foothills Medical Centre, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9.
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Davenport A. Why do hypertonic citrate locks lead to dialysis catheter malfunction; more than a weighty problem? Nephrol Dial Transplant 2012; 27:2621-4. [PMID: 22802579 DOI: 10.1093/ndt/gfs274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, London, UK.
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Ramanathan V, Riosa S, Al-Sharif AH, Mansouri MD, Tranchina A, Kayyal T, Abreo AP, Aslam S, Nassar G, Darouiche RO. Characteristics of Biofilm on Tunneled Cuffed Hemodialysis Catheters in the Presence and Absence of Clinical Infection. Am J Kidney Dis 2012; 60:976-82. [DOI: 10.1053/j.ajkd.2012.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 06/12/2012] [Indexed: 12/17/2022]
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Minimizing hemodialysis catheter dysfunction: an ounce of prevention. Int J Nephrol 2012; 2012:170857. [PMID: 22518310 PMCID: PMC3299246 DOI: 10.1155/2012/170857] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 10/10/2011] [Indexed: 11/17/2022] Open
Abstract
The maintenance of tunneled catheter (TC) patency is critical for the provision of adequate hemodialysis in patients who are TC-dependent. TC dysfunction results in the need for costly and inconvenient interventions, and reduced quality of life. Since the introduction of TCs in the late 1980s, heparin catheter lock has been the standard prophylactic regimen for the prevention of TC dysfunction. More recently, alternative catheter locking agents have emerged, and in some cases have shown to be superior to heparin lock with respect to improving TC patency and reducing TC-associated infections. These include citrate, tissue plasminogen activator, and a novel agent containing sodium citrate, methylene blue, methylparaben, and propylparaben. In addition, prophylaxis using oral anticoagulants/antiplatelet agents, including warfarin, aspirin, ticlodipine, as well as the use of modified heparin-coated catheters have also been studied for the prevention of TC dysfunction with variable results. The use of oral anticoagulants and/or antiplatelet agents as primary or secondary prevention of TC dysfunction must be weighed against their potential adverse effects, and should be individualized for each patient.
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