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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 6  |  Page : 159-163

Bacteremia and thrombotic complications of temporary hemodialysis catheters: Experience of a single center in Morocco


1 Department of Nephrology Dialysis and Renal Transplantation, Faculty of Medicine, Mohammed V Military Hospital, Mohammed V-Souissi University, Rabat, Morocco
2 Department of Nephrology and Dialysis, 5th Military Hospital, Guelmim, Morocco

Date of Web Publication8-Nov-2017

Correspondence Address:
Hicham Rafik
Department of Nephrology Dialysis and Renal Transplantation, Mohammed V Military Hospital, Faculty of Medicine, Mohammed V-Souissi University, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmbs.ijmbs_25_17

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  Abstract 


Background: The use of central venous catheters is essential in hemodialysis care, but it is associated with infectious and thrombotic complications. The aim of this study is to determine rates and risk factors of hemodialysis catheter-related bacteremia and thrombotic complications from a Moroccan single center to set prevention policies. Materials and Methods: The trial was designed as a prospective observational study including all patients who required a temporary hemodialysis catheter more than 48 h. Baseline demographic and clinical data including age, sex, causes of kidney failure, comorbidities, indication for insertion, catheter insertion sites, and duration of use were collected. Patients were followed up since the insertion of catheter to its removal. Results: A total of 126 hemodialysis catheters were inserted at different sites in 93 patients for the following reasons: the absence of vascular access in patients with end-stage renal disease in 55 cases (43.65%), vascular access dysfunction or infection in 45 cases (35.71%), and acute kidney injury in 26 (20.63%). During follow-up, 15 catheters (11.9%) were complicated by bacteremia, resulting in a rate of 6.68 per 1000 catheter days. Risk factors associated with catheter-related bacteremia were diabetes (odds ratio [OR] =26.018; P = 0.017) and advanced age (OR = 1.105; P = 0.045). Causative microorganisms were dominated by coagulase-negative staphylococci in 46.66%. Twenty-four thrombotic complications (19.04%) were documented with an incidence of 10.69/1000 catheter-days. Among these complications, 18 were dysfunction of catheter (14.28%, 8.01/1000 catheter-days) and 6 were vein thrombosis (4.76%, 2.67/1000 catheter-days). Lower serum albumin levels was the unique risk factor (OR = 0.801; P = 0.042). Conclusions: Early diagnosis of chronic kidney disease and creation of arteriovenous fistula may lower the incidence of catheter use in hemodialysis.

Keywords: Central venous catheter, dysfunction, hemodialysis, infection, vascular access


How to cite this article:
Rafik H, Bahadi A, Aatif T, Sobhi A, El Kabbaj D. Bacteremia and thrombotic complications of temporary hemodialysis catheters: Experience of a single center in Morocco. Ibnosina J Med Biomed Sci 2017;9:159-63

How to cite this URL:
Rafik H, Bahadi A, Aatif T, Sobhi A, El Kabbaj D. Bacteremia and thrombotic complications of temporary hemodialysis catheters: Experience of a single center in Morocco. Ibnosina J Med Biomed Sci [serial online] 2017 [cited 2020 Apr 1];9:159-63. Available from: http://www.ijmbs.org/text.asp?2017/9/6/159/217868




  Introduction Top


Arteriovenous fistula (AVF) is the reference vascular access in hemodialysis. The use of central venous catheters should be reserved for emergencies or in case of AVF dysfunction.[1] According to the United States Renal Data System (USRDS), a catheter was used in 62.6% of patients for vascular access for their first hemodialysis treatment in the US, while only 16% of patients were using an AVF for their first hemodialysis session. About 81% of patients were using a catheter as the unique vascular access or while waiting for AVF maturation.[2]

Hemodialysis catheters expose to a risk of infection and thrombotic complications. Infection is the most frequent complication of hemodialysis catheters and is a major cause of morbidity and mortality in hemodialysis patients.[3]

There were no data regarding hemodialysis catheters-related complications in Rabat, Morocco.

The aim of this study was to investigate rates and risk factors of temporary hemodialysis catheters-related complications, especially bacteremia and thrombosis, in our hemodialysis center to improve their prevention.


  Materials and Methods Top


Study population

The study was designed as a prospective observational study and was conducted over a period of 2 years 2015–2016 at the Department of Nephrology and Hemodialysis in Military Hospital of Rabat, Morocco. The study included all patients who required a temporary hemodialysis catheter more than 48 h. Patients were followed up since the insertion of catheter to its removal. The study protocol was approved by the Committee on Ethics and Research of the institution.

Data collection

Baseline demographic and clinical data including age, sex, causes of kidney failure, comorbidities, indication for insertion, catheter insertion sites, and duration of use were collected

Catheter insertion

All catheters used were double-lumen nontunneled in silico ne. Central vein catheterization was performed using the Seldinger technique and maximal sterile-barrier precautions including a mask, a cap, a sterile gown, sterile gloves, and a large sterile drape. Povidone-iodine-based solutions were used to prepare the skin before insertion of the catheter. The catheter insertion was not echo-guided. The catheter exit site and the two ports were dressed with a permeable dressing after each dialysis treatment. Catheter lumens were locked with a volume of unfractionated heparin equivalent to the internal volume of the lumen. Each time before the catheter was opened, the exit site of the catheter was carefully checked for any redness, swelling, bleeding or exudate, and patients were asked to report any fever episodes. The catheter was removed when it was no longer required or when a complication developed. Catheter tip culture was a routine after the catheter was removed.

Definitions

Complications of the catheter were determined as follows:

  • Catheter-related bacteremia was defined by positive blood cultures obtained from catheter lock solution and/or peripheral blood in a symptomatic patient with no clinical evidence of infections in other loci
  • Thrombotic complications include catheter dysfunction and venous thrombosis; catheter dysfunction was defined as poor blood flow less than 200 ml/min for at least 30 min.


Statistical analysis

Data with continuous variables were presented as mean ± standard deviation. Categorical variables were presented as effective and percentage. The rate of catheter complication was calculated as an incidence per 1000 catheter-days. Logistic regression was performed to investigate the risk factors influencing the outcomes of catheter complications. P < 0.05 was considered statistically significant. Statistical analysis was performed with SPSS V17 for Windows statistical package (SPSS Inc., Chicago, IL, USA).


  Results Top


Patients and catheters data

A total of 126 temporary hemodialysis catheters were inserted at different sites in 93 patients over 2 years. The femoral vein was used for cannulation in 102 cases: right femoral vein in 76 and left femoral vein in 26, 23 were inserted in the right internal jugular vein and one in the left internal jugular vein. Twenty-nine patients had several periods of catheterism: Two episodes (25 cases) and 3 episodes (4 cases).

Sixty patients were males and 33 were females, their mean age was 55.13 ± 15.20 years. Causes of kidney failure were: Diabetes 36 cases (38.7%), glomerulonephritis 18 cases (19.35%), hypertension 14 cases (15.05%), tubulointerstitial nephropathy10 cases (10.75%), unknown 7 cases (7.52%), obstructive kidney failure 5 cases (5.37%), 2 cases of cardiorenal syndrome (2.15%), and one case of polycystic kidney disease (1.07%) [Table 1].
Table 1: Patients characteristics

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Indications for insertion of catheter included: the absence of vascular access in patients with end-stage renal disease in 55 cases (43.65%), vascular access dysfunction or infection in 45 cases (35.71%), acute kidney injury in 26 (20.63%) [Table 2].
Table 2: Indications for hemodialysis catheters implantation and complications according to site of insertion

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The median duration of implantation of catheters was 15 days and 94 catheters (74.6%) exceeded recommended a time of use. Complications occurred in 39 catheters (30.95%): 18 dysfunctions (14.28%), 15 infections (11.9%), and 6 vein thrombosis (4.76%) [Table 2].

Catheter-related bacteremia

During follow-up, 15 catheters were complicated by bacteremia, resulting in a rate of 6.68 per 1000 catheter days: 12 of the 102 catheters inserted at the femoral site (11.46%) and 3 of the 24 catheters (12.5%) inserted at the internal jugular site. The average time between catheter insertion and development of infection was 17.5 days ranging between 3 and 38 days; 80% of infected catheters exceeded recommended a time of use.

The incidence of bacteremia on femoral site is higher compared to the jugular site (7.17/1000 catheter-days and 5.24/1000 catheter-days respectively), but femoral insertion site was not associated with infection (P = 0.921). Risk factors associated with catheter-related bacteremia were diabetes (odds ratio [OR] =26.018; P = 0.017) and advanced age (OR = 1.105; P = 0.045). The results are summarized in [Table 3].
Table 3: Risk factors of catheter complications

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Two patients had complications secondary to their catheter infection: A splenic infarction and a case of multiple septic embolisms (spondylodiscitis, ischemic cerebral vascular accident, and pulmonary staphylococcal infection).

The microorganisms isolated included were: Coagulase-negative staphylococci (46.66% of infected catheters), Staphylococcus aureus (33.33%),  Escherichia More Details coli (6.66%), Klebsiella pneumoniae (6.66%), and Enterococcus foecalis (6.66%).

Thrombotic complications

In total, 24 thrombotic complications (19.04% of catheters) were documented with an incidence of 10.69/1000 catheter-days. Among these complications, 18 were dysfunction of catheter (14.28%, 8.01/1000 catheter-days) and 6 were vein thrombosis (4.76%, 2.67/1000 catheter-days). Lower serum albumin levels was the unique risk factor (OR = 0.801; P = 0.042) [Table 3].

Rates of thrombotic complications in catheters inserted in femoral site and those inserted in jugular site were 12.55/1000 catheter-days and 5.24/1000 catheter-days, respectively. While catheter-related thrombotic complications rates were high in femoral site, femoral insertion site was no longer significantly associated with thrombosis (P = 0.368).


  Discussion Top


About 100% of catheters used in this study were nontunneled. Tunneled catheters were used as permanent vascular access in patients who had exhausted their vascular capital. According to European Recommendations for Good Practice in hemodialysis, nontunneled catheters are indicated only in an emergency and should be replaced as soon as possible by tunneled catheters to reduce the risk of infection.[4] About 43.65% of hemodialysis catheters were placed in an emergency context in patients who have never had any medical follow-up and arrived in end stage of chronic kidney disease. This could be reduced by earlier referral and more timely vascular access creation. Internal jugular vein is the first recommended site for its low morbidity and its performance. Femoral vein leads to more infectious complications and subclavian vein has not been used anymore because it causes central venous stenosis.[5] The insertion site was chosen according to the experience of the operator, and right femoral site was the most used in our study (60.31%). According to the guidelines, recommended a duration of use of temporary hemodialysis catheters should be 05 days in femoral site and up to 21 days in jugular.[6] Each time these periods are exceeded, infectious complications occur;[7] this was also noted in our series. Indeed, the occurrence of infection was observed on catheters that exceeded recommended time of use in 80%.

Infection is the most frequent and severe complication of hemodialysis catheters.[8],[9],[10] The incidence of catheter-related bacteremia was 6.68/1000 catheter days. That incidence of bacteremia in our series is higher compared to the literature. Previous studies showed that the rate of catheter-related bacteremia was about 0.037–0.18–3.1/1000 catheter-days.[9],[11],[12] That high rate in our study may be explained by several assumptions: 38.7% of patients were diabetic; lower level of education; wide use of femoral insertion site; exceeding recommended time of use; use of heparin as a catheter locking solution. Citrate locks reduce catheter-related infections.[13] Several risk factors have been incriminated in catheter infection: Advanced age >65 years, nasal carriage of S. aureus, diabetes mellitus, femoral insertion site, duration of catheter placement >10 days, dialysis sessions >5 per catheter and lower serum albumin level.[12],[14],[15],[16],[17] In our study, risk factors were diabetes and advanced age. Despite that incidence of bacteremia on femoral site is higher compared to jugular site, insertion site was not a risk factor for infection in our study. Similarly, Parienti et al. demonstrated that risk of infection does not vary with anatomical site and that internal jugular site does not reduce this risk compared to the femoral.[18]

Coagulase-negative staphylococci and S. aureus were the most implicated germs in hemodialysis catheters infections in our series and the literature.[10],[12]

The high incidence of catheter dysfunction in our study (8.01/1000 catheter-days) was similar to that reported by Napalkov et al. in a study including 3213 hemodialysis patients (8.6/1000 catheter-days), but was lower to that mentioned by Wang et al.(12.86/1000 catheter-days).[15],[19] Patients with uremia have high homocysteine levels and microinflammation, which could increase risk of thrombogenesis.[20] Otherwise, catheter insertions could damage the vascular wall, and exposure of the endothelium could promote platelet adhesion and activate the endogenous coagulation pathway.[21] The risk of catheter dysfunction was not affected by hemoglobin level and access via femoral vein in contrast to Wang et al. report.[15] Lower serum albumin level was the unique risk factor in our study.

The rarity of venous thrombosis in our study could be explained by the use of flexible silicone catheters that have lower risk of venous thrombosis than rigid polyvinyl catheters,[22] and by the possibility of underestimation of their frequency without systematic imaging. Thrombotic complications are sometimes asymptomatic or may manifest as iterative dysfunction or by an increase in venous pressure when making an anterior facial vein on the same side.[23]


  Conclusions Top


Hemodialysis catheters-related complications were observed in one-third of cases. Almost, half of these catheters were implanted for lack of vascular access in patients with end-stage renal disease.

Our results confirm the importance of early referral of chronic kidney disease to nephrologists especially diabetics.

Authors' contributions

All authors were responsible for the conduct of the study, data collection, and analysis. They drafted and reviewed the manuscript and approved its final version.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Compliance with ethical principles

The study protocol was approved by the Committee on Ethics and Research of the institution and informed consent was obtained from all participants before the study.



 
  References Top

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Thomson P, Stirling C, Traynor J, Morris S, Mactier R. A prospective observational study of catheter-related bacteraemia and thrombosis in a haemodialysis cohort: Univariate and multivariate analyses of risk association. Nephrol Dial Transplant 2010;25:1596-604.  Back to cited text no. 3
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Canaud B, Fouque D. European recommendations for good practice in hemodialysis. Part two. Nephrol Ther 2008;4:115-24.  Back to cited text no. 4
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Oliver MJ, Callery SM, Thorpe KE, Schwab SJ, Churchill DN. Risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: A prospective study. Kidney Int 2000;58:2543-5.  Back to cited text no. 7
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Randriamanantsoa LN, Rajaonera TA, Ramanamidora DA, Ravalisoa ML, Randriamarotia HW, Rabenantoandro R, et al. Hemodialysis central venous catheter complications in the hemodialysis centers in Antananarivo. Anesthesia-resuscitation and Emergency Medicine Magazine 2011;3:1-5.  Back to cited text no. 11
    
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Weijmer MC, van den Dorpel MA, Van de Ven PJ, ter Wee PM, van Geelen JA, Groeneveld JO, et al. Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol 2005;16:2769-77.  Back to cited text no. 13
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Jean G, Charra B, Chazot C, Vanel T, Terrat JC, Hurot JM, et al. Risk factor analysis for long-term tunneled dialysis catheter-related bacteremias. Nephron 2002;91:399-405.  Back to cited text no. 14
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Bozzetti F, Scarpa D, Terno G, Scotti A, Ammatuna M, Bonalumi MG, et al. Subclavian venous thrombosis due to indwelling catheters: A prospective study on 52 patients. JPEN J Parenter Enteral Nutr 1983;7:560-2.  Back to cited text no. 22
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  [Table 1], [Table 2], [Table 3]



 

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