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van Oevelen M, Heggen BDC, Abrahams AC, Rotmans JI, Snoeijs MGJ, Vernooij RWM, van Buren M, Meijvis SCA. Central venous catheter-related complications in older haemodialysis patients: A multicentre observational cohort study. J Vasc Access 2023; 24:1322-1331. [PMID: 35360988 PMCID: PMC10714686 DOI: 10.1177/11297298221085225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/12/2022] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Central venous catheters (CVC) remain a commonly used vascular access option in haemodialysis, despite guidelines advising to preferably use arteriovenous fistulae. Compared to younger patients, the risk-benefit ratio of CVC in older patients might be more beneficial, but previous studies mainly focussed on catheter-related bacteraemia and/or assessed tunnelled CVC (TCVC) only. This study's aim was to compare all catheter-related infections and malfunctions in older patients with younger patients using all CVC subtypes. MATERIALS AND METHODS We used data from DUCATHO, a multicentre observational cohort study in The Netherlands. All adult patients in whom a CVC was placed for haemodialysis between 2012 and 2016 were included. The primary endpoint was the occurrence of catheter-related infections, comparing patients aged ⩾70 years with patients aged <70 years (reference). As secondary endpoints, catheter malfunctions and catheter removal due to either infection or malfunction were assessed. Using Cox proportional hazards and recurrent events modelling, hazard ratios (HR) with 95% confidence intervals (CI) were calculated with adjustment of prespecified confounders. Additionally, endpoints were assessed for non-tunnelled CVC (NTCVC) and TCVC separately. RESULTS A total of 1595 patients with 2731 CVC (66.5% NTCVC, 33.1% TCVC) were included. Of these patients, 1001 (62.8%) were aged <70 years and 594 (37.2%) ⩾70 years. No statistically significant difference was found for the occurrence of catheter-related infections (adjusted HR 0.80-95% CI 0.62-1.02), catheter malfunction (adjusted HR 0.94-95% CI 0.75-1.17) and catheter removal due to infection or malfunction (adjusted HR 0.94-95% CI 0.80-1.11). Results were comparable when assessing NTCVC and TCVC separately. CONCLUSION Patients aged ⩾70 to <70 years have a comparable risk for the occurrence of catheter-related infections and catheter malfunction. These findings may help when discussing treatment options with older patients starting haemodialysis and may inform the current debate on the best vascular access for these patients.
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Affiliation(s)
- Mathijs van Oevelen
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Boudewijn DC Heggen
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten GJ Snoeijs
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robin WM Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
| | - Sabine CA Meijvis
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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Massouh A, Kwan SW, Fidelman N, Higgins M, Abujudeh H, Charalel RA, Guimaraes MS, Gupta A, Lam A, Majdalany BS, Patel PJ, Stadtlander KS, Stillwell T, Teo EYL, Tong RT, Kapoor BS. ACR Appropriateness Criteria® Central Venous Access Device and Site Selection. J Am Coll Radiol 2023; 20:S3-S19. [PMID: 37236750 DOI: 10.1016/j.jacr.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
The use of central venous access devices is ubiquitous in both inpatient and outpatient settings, whether for critical care, oncology, hemodialysis, parenteral nutrition, or diagnostic purposes. Radiology has a well-established role in the placement of these devices due to demonstrated benefits of radiologic placement in multiple clinical settings. A wide variety of devices are available for central venous access and optimal device selection is a common clinical challenge. Central venous access devices may be nontunneled, tunneled, or implantable. They may be centrally or peripherally inserted by way of veins in the neck, extremities, or elsewhere. Each device and access site presents specific risks that should be considered in each clinical scenario to minimize the risk of harm. The risk of infection and mechanical injury should be minimized in all patients. In hemodialysis patients, preservation of future access is an additional important consideration. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Alan Massouh
- Research Author, University of Utah, Salt Lake City, Utah.
| | - Sharon W Kwan
- University of Utah, Salt Lake City, Utah; and JACR editorial board
| | - Nicholas Fidelman
- Panel Chair, University of California San Francisco, San Francisco, California
| | - Mikhail Higgins
- Panel Vice-Chair, Boston University School of Medicine, Boston, Massachusetts
| | - Hani Abujudeh
- Detroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan
| | - Resmi A Charalel
- Weill Cornell Medicine, New York, New York; and SIR Quality Data Analytics Committee Co-Chair
| | | | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Alexander Lam
- University of California, San Francisco, San Francisco, California
| | | | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Terri Stillwell
- University of Michigan, Ann Arbor, Michigan; Infectious Diseases Society of America; PIDS Education Committee; SHEA Education Committee; and Panelist, IDSA
| | - Elrond Y L Teo
- Piedmont Atlanta Hospital, Atlanta, Georgia; Society of Critical Care Medicine
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van Roeden S, van Oevelen M, Abrahams AC, Dekker FW, Rotmans JI, Meijvis SCA. The best solution down the line: an observational study on taurolidine- versus citrate-based lock solutions for central venous catheters in hemodialysis patients. BMC Nephrol 2021; 22:308. [PMID: 34517829 PMCID: PMC8439004 DOI: 10.1186/s12882-021-02519-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION To prevent infection and thrombosis of central venous catheters (CVCs) in hemodialysis patients, different CVC lock solutions are available. Taurolidine-based solutions and citrate in different concentrations are frequently used, but no definite conclusions with regard to superiority have been drawn. METHODS In this retrospective, observational, multicenter study, we aimed to assess the risk for removal of CVC due to infection or catheter malfunction in hemodialysis patients with CVC access for different lock solutions: taurolidine, high-concentrated citrate (46.7%) and low-concentrated citrate (4 or 30%). A multivariable Cox-regression model was used to calculate hazard ratio's (HR). RESULTS We identified 1514 patients (median age 65 years, 59% male). In 96 (6%) taurolidine-based lock solutions were used. In 1418 (94%) citrate-based lock solutions were used (high-concentrated 73%, low-concentrated 20%). Taurolidine-based lock solutions were associated with a significantly lower hazard for removal of CVC due to infection or malfunction combined (HR 0.34, 95% CI 0.19-0.64), and for removal of CVC due to infection or malfunction separately (HR 0.36, 95% CI 0.15-0.88 and HR0.33, 95% CI 0.14-0.79). High-concentrated citrate lock solutions were not associated with a decreased hazard for our outcomes, compared to low-concentrated citrate lock solutions. CONCLUSION Removal of CVC due to infection or catheter malfunction occurred less often with taurolidine-based lock solutions. We present the largest cohort comparing taurolidine- and citrate-based lock solutions yet. However, due to the retrospective observational nature of this study, conclusions with regard to superiority should be drawn with caution.
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Affiliation(s)
- Sonja van Roeden
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Mathijs van Oevelen
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Sabine C A Meijvis
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Heidempergher M, Sabiu G, Orani MA, Tripepi G, Gallieni M. Targeting COVID-19 prevention in hemodialysis facilities is associated with a drastic reduction in central venous catheter-related infections. J Nephrol 2021; 34:345-353. [PMID: 33369726 PMCID: PMC7768271 DOI: 10.1007/s40620-020-00900-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND In hemodialysis (HD) patients, central venous catheter (CVC) related bloodstream infections are a major cause of morbidity and mortality. Hygienic precautions are a key aspect of dialysis care for infection prevention, but they are not sufficient to completely avoid the occurrence of CVC related infections. During the COVID-19 pandemic, hygienic precautions for preventing viral transmission have been markedly reinforced. We evaluated their effects on CVC-related infection rates. METHODS An observational retrospective study was conducted in two hemodialysis units of the same institution treating 215 chronic hemodialysis patients, 71 of whom are currently (33%) using a CVC. In the CVC cohort, we compared data on catheter-related infection rates during the maximum spread of the COVID-19 pandemic in Italy (February to May 2020) with data from the same period of the previous year and with the whole of 2019. RESULTS In 2019, we recorded a catheter-related bloodstream infection (CRBSI) rate of 1.19 (95% CI 0.81-1.68)/1000 days [2.07 (95% CI 1.12-3.52)/1000 days in the Feb-May 2019 period] and a tunnel and exit-site infection rate of 0.82 (95% CI 0.51-1.24)/1000 days [1.04 (95% CI 0.41-2.15)/1000 days in the Feb-May 2019 period]. Infection rates drastically decreased during the COVID-19 pandemic, with just one catheter-related bloodstream infection being recorded. Catheter-related bloodstream infection rates showed a significant reduction to 0.20 (95% CI 0.01-0.9)/1000 days (p < 0.05 and p < 0.005 compared to 2019 and to Feb-May 2019, respectively) and a non-significant reduction in tunnel and exit-site infections to 0.6 (95% CI 0.15-1.6)/1000 days. CONCLUSIONS The observed 91% reduction in catheter-related bloodstream infections compared to the same period in 2019 [IRR 0.09 (95% CI 0.002-0.64)] and the 83% reduction compared to the whole of 2019 [IRR 0.17 (95% CI 0.004-1.009)] suggest that a stricter implementation of hygienic precautions in the dialysis setting can markedly improve the problem of CVC-related infections.
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Affiliation(s)
| | - Gianmarco Sabiu
- Nephrology Unit, ASST Fatebenefratelli Sacco, Milano, Italy
- School of Nephrology, Università di Milano, Milano, Italy
| | | | - Giovanni Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
| | - Maurizio Gallieni
- Nephrology Unit, ASST Fatebenefratelli Sacco, Milano, Italy.
- School of Nephrology, Università di Milano, Milano, Italy.
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università di Milano, via G.B. Grassi, 74, 20157, Milano, Italy.
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Fused Deposition Modelling as a Potential Tool for Antimicrobial Dialysis Catheters Manufacturing: New Trends vs. Conventional Approaches. COATINGS 2019. [DOI: 10.3390/coatings9080515] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The rising rate of individuals with chronic kidney disease (CKD) and ineffective treatment methods for catheter-associated infections in dialysis patients has led to the need for a novel approach to the manufacturing of catheters. The current process requires moulding, which is time consuming, and coated catheters used currently increase the risk of bacterial resistance, toxicity, and added expense. Three-dimensional (3D) printing has gained a lot of attention in recent years and offers the opportunity to rapidly manufacture catheters, matched to patients through imaging and at a lower cost. Fused deposition modelling (FDM) in particular allows thermoplastic polymers to be printed into the desired devices from a model made using computer aided design (CAD). Limitations to FDM include the small range of thermoplastic polymers that are compatible with this form of printing and the high degradation temperature required for drugs to be extruded with the polymer. Hot-melt extrusion (HME) allows the potential for antimicrobial drugs to be added to the polymer to create catheters with antimicrobial activity, therefore being able to overcome the issue of increased rates of infection. This review will cover the area of dialysis and catheter-related infections, current manufacturing processes of catheters and methods to prevent infection, limitations of current processes of catheter manufacture, future directions into the manufacture of catheters, and how drugs can be incorporated into the polymers to help prevent infection.
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