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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 952] [Impact Index Per Article: 238.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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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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Fisher M, Golestaneh L, Allon M, Abreo K, Mokrzycki MH. Prevention of Bloodstream Infections in Patients Undergoing Hemodialysis. Clin J Am Soc Nephrol 2019; 15:132-151. [PMID: 31806658 PMCID: PMC6946076 DOI: 10.2215/cjn.06820619] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Bloodstream infections are an important cause of hospitalizations, morbidity, and mortality in patients receiving hemodialysis. Eliminating bloodstream infections in the hemodialysis setting has been the focus of the Centers for Disease Control and Prevention (CDC) Making Dialysis Safer for Patients Coalition and, more recently, the CDC's partnership with the American Society of Nephrology's Nephrologists Transforming Dialysis Safety Initiative. The majority of vascular access-associated bloodstream infections occur in patients dialyzing with central vein catheters. The CDC's core interventions for bloodstream infection prevention are the gold standard for catheter care in the hemodialysis setting and have been proven to be effective in reducing catheter-associated bloodstream infection. However, in the United States hemodialysis catheter-associated bloodstream infections continue to occur at unacceptable rates, possibly because of lapses in adherence to strict aseptic technique, or additional factors not addressed by the CDC's core interventions. There is a clear need for novel prophylactic therapies. This review highlights the recent advances and includes a discussion about the potential limitations and adverse effects associated with each option.
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Affiliation(s)
- Molly Fisher
- Division of Nephrology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Ladan Golestaneh
- Division of Nephrology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Kenneth Abreo
- Division of Nephrology, Louisiana State University Health at Shreveport, Shreveport, Louisiana
| | - Michele H Mokrzycki
- Division of Nephrology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York;
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Advances in the prevention and management of central-line-associated bloodstream infections: The role of chelator-based catheter locks. Infect Control Hosp Epidemiol 2019; 40:1036-1045. [PMID: 31230604 DOI: 10.1017/ice.2019.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The proper functioning of central lines is imperative for the management of patients with cancer or on hemodialysis. However, these lifelines can become infected and can malfunction.Chelators such as citrate and EDTA have been widely studied alone or in combination with other antimicrobial agents in catheter lock solutions to prevent catheter-related bloodstream infections and to maintain catheter patency. Given their anticoagulation, antiplatelet aggregation, antibiofilm, antimicrobial activity, safety profile, as well as their low cost, chelators have long been considered alternatives to heparin and a vital component of catheter lock solutions. In this review, we present a detailed summary of the properties of chelators and in vitro and in vivo studies of chelator-containing lock solutions.
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The NeutraClear® needleless connector is equally effective against catheter colonization compared to MicroClave®. J Vasc Access 2017; 18:415-418. [PMID: 28777419 DOI: 10.5301/jva.5000775] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2017] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Neutral-valve closed-system connectors can reduce the frequency of catheter colonization. Commercially available closed system connectors need to be tested and compared with each other to assess how they protect against contamination. We aimed to compare, in vitro, the efficacy of connectors NeutraClear® and MicroClave® against contamination under conditions of daily clinical practice. METHODS The model consisted of a set of 200 blood culture bottles (BCBs) with a cannula inserted (100 closed with NeutraClear® and 100 closed with MicroClave®) that were assessed in two experiments while instilling 1 mL of saline: manipulation based on the standard of care and manipulation using gloves impregnated with a 0.05 McFarland Staphylococcus aureus solution. The BCBs were incubated in a BACTEC System at 37°C under continuous shaking for up to 7 days. When a bottle turned positive, 100 µL of the fluid was cultured. The positivity rate and time to positivity of the BCB in each experiment was compared. RESULTS In the aseptic model in the NeutraClear® and MicroClave® groups, only 1 BCB and 2 BCBs were positive, respectively, (p = 0.55). In the contaminated model, all BCBs were positive in both groups at the end of the incubation time. We did not find differences for the MTP between NeutraClear® and MicroClave® (36.04 vs. 20.13 hours, p = 0.09). CONCLUSIONS The NeutraClear® needleless connector proved to be as efficient as the MicroClave® connector in the prevention of catheter colonization and migration of S. aureus from the surface to the inside of the hub in an in vitro model.
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Guembe M, Pérez-Granda MJ, Cruces R, Alcalá L, Bouza E. The Tego™ needleless connector for hemodialysis catheters may protect against catheter colonization. Eur J Clin Microbiol Infect Dis 2016; 35:1341-5. [PMID: 27189077 DOI: 10.1007/s10096-016-2670-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/03/2016] [Indexed: 11/28/2022]
Abstract
Catheter connectors used in hemodialysis patients are those with open caps to manage high blood flows. However, current guidelines for the prevention of catheter infections recommend closed connectors. Tego™ is a closed connector designed to enable high blood flows. We used an in vitro model to compare the efficacy of Tego™ against contamination with that of standard caps in a real-life practice scenario. The model consisted of 200 blood culture bottles (BCB) with an inserted cannula closed either with Tego™ (100) or with open caps (100). BCB were manipulated using two different methods: under aseptic conditions and with gloves contaminated with a 0.05 McFarland Staphylococcus aureus solution. The BCB were incubated at 37 °C under continuous shaking for up to 7 days or until positive. When a BCB turned positive, 100 μL of the fluid was cultured. The positivity rate and time to positivity of the BCB in each method were compared. Overall, 4.0 % of BCB with Tego™ and 52.0 % of BCB with open caps were positive in the sterile model (p < 0.001), whereas all BCB in the contamination model were positive. We did not find differences regarding the median time (hours) to positivity between Tego™ and the standard cap in the contamination model (19.04 vs. 17.87, p = 0.465). In our model, Tego™ proved to be better than the standard cap for the prevention of contamination when the device was handled under optimal conditions. Moreover, it was as efficient as the standard catheter cap in the contamination model.
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Affiliation(s)
- M Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, C/. Dr. Esquerdo, 46, 28007, Madrid, Spain. .,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.
| | - M J Pérez-Granda
- Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Cruces
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, C/. Dr. Esquerdo, 46, 28007, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | - L Alcalá
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, C/. Dr. Esquerdo, 46, 28007, Madrid, Spain
| | - E Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, C/. Dr. Esquerdo, 46, 28007, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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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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Brunelli SM, Njord L, Hunt AE, Sibbel SP. Use of the Tego needlefree connector is associated with reduced incidence of catheter-related bloodstream infections in hemodialysis patients. Int J Nephrol Renovasc Dis 2014; 7:131-9. [PMID: 24729725 PMCID: PMC3979783 DOI: 10.2147/ijnrd.s59937] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Catheter-related bloodstream infections (CRBSIs) are common in hemodialysis patients using central venous catheters, and catheter occlusion also occurs frequently. The Tego needlefree connector was developed to reduce the incidence of these complications; however, existing studies of its effectiveness and safety are limited. MATERIALS AND METHODS This retrospective analysis compared outcomes among patients of a large dialysis organization receiving in-center hemodialysis using a central venous catheter with either the Tego connector or standard catheter caps between October 1 and June 30, 2013. Incidence rates for intravenous (IV) antibiotic starts, receipt of an IV antibiotic course, positive blood cultures, mortality, and missed dialysis treatments were calculated, and incidence-rate ratios (IRRs) were estimated using Poisson regression models. Utilization of erythropoiesis-stimulating agents (ESAs) and thrombolytics was described for each patient-month and compared using mixed linear models. Models were run without adjustment, adjusted for covariates that were imbalanced between cohorts, or fully adjusted for all potential confounders. RESULTS The analysis comprised 10,652 Tego patients and 6,493 controls. Tego use was independently associated with decreased risk of CRBSI, defined by initiation of IV antibiotics (adjusted IRR 0.92, 95% confidence interval [CI] 0.87-0.97) or initiation of IV antibiotic course (adjusted IRR 0.89, 95% CI 0.84-0.95). Tego use was independently associated with decreased rate of missed dialysis treatments (adjusted IRR 0.98, 95% CI 0.97-1.00); no significant difference between Tego and control cohorts was observed with respect to mortality. Tego use was associated with decreased likelihood of thrombolytic use (adjusted per-month probability of 5.6% versus 6.2% for controls) and lower utilization of ESAs in study months 7-9. CONCLUSION Use of the Tego connector may reduce the risk of CRBSI and result in lower utilization of thrombolytics, antibiotics, and ESAs, as well as fewer missed dialysis treatments.
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Affiliation(s)
| | - Levi Njord
- DaVita HealthCare Partners, Inc, Denver, CO, USA
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Mustafa RA, Zimmerman D, Rioux JP, Suri RS, Gangji A, Steele A, MacRae J, Pauly RP, Perkins DN, Chan CT, Copland M, Komenda P, McFarlane PA, Lindsay R, Pierratos A, Nesrallah GE. Vascular Access for Intensive Maintenance Hemodialysis: A Systematic Review for a Canadian Society of Nephrology Clinical Practice Guideline. Am J Kidney Dis 2013; 62:112-31. [DOI: 10.1053/j.ajkd.2013.03.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 03/27/2013] [Indexed: 11/11/2022]
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