Reduction of biofilm formation with trisodium citrate in haemodialysis catheters: a randomized controlled trial.
ABSTRACT Formation of an intraluminal microbial biofilm is noted to play a significant role in the development of catheter-related infections (CRIs). Recently, it has been demonstrated that trisodium citrate (TSC) has superior antimicrobial effects over heparin for catheter locking. In this randomized controlled trial, we compared the influence of catheter locking with heparin and TSC on the in vivo intraluminal biofilm formation in haemodialysis catheters.
Six patients were studied from the time of catheter insertion for haemodialysis treatment. They were randomly assigned to TSC 30% or heparin 5000 U/ml for catheter locking for the duration of 1 month. After elective guidewire exchange of the catheter, the locking solution was also changed. After removal, catheters were dissected in three segments and examined by standardized scanning electron microscopy (SEM) to assess quantitative biofilm formation. Furthermore, standardized cultures of all segments were performed to identify any microorganisms.
In catheters filled with TSC, the average coverage by biofilm was 16% versus 63% in the heparin group (P < 0.001). A total of eight subsegments were associated with local catheter infection in the patients who were randomized to heparin locking versus three subsegments who were assigned to TSC (P < 0.05).
Our study demonstrates that using TSC 30% for catheter locking reduces the formation of microbial biofilm in haemodialysis catheters and culture-positive colonization. It is likely that this is the explanation for the observed prevention of CRIs by TSC locking.
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ABSTRACT: A complication of long-term use of tunneled cuffed catheters for hemodialysis is the high rate of infection and thrombus-related dysfunction. Specific mechanical features of tunneled cuffed catheters may improve hemodynamic performance and decrease thrombosis and infection rates. However, there currently is no proven advantage of one design over another. Single-center randomized clinical trial. 302 hemodialysis patients who required a tunneled cuffed catheter as temporary or definite vascular access. Palindrome Symmetric Tip Dialysis Catheter or HemoStar Long-Term Hemodialysis Catheter. The primary end point was primary assisted patency. Secondary end points were incidence of catheter-related bloodstream infections (CRBSIs), thrombosis, and 2 indicators of rheologic function: mean effective blood flow rate and urokinase use. Mean primary assisted patency was 135.9 days for Palindrome and 136.5 days for HemoStar (P=0.8). Definite CRBSI occurred in 0.24 and 0.10/1,000 catheter-days for Palindrome and HemoStar, respectively (P=0.3). Removal rates for thrombosis that could not be resolved with thrombolysis were 0.53 and 0.43/1,000 catheter-days for Palindrome and HemoStar, respectively (P=0.7). Urokinase use was lower for Palindrome than for HemoStar, as evidenced by a lower number of urokinase infusions/1,000 catheter-days (17 and 35; P<0.001) and higher number of catheters that never required thrombolysis (58% and 45%; P=0.03). Mean effective blood flow rate was higher for Palindrome than for HemoStar (333 and 304mL/min; P<0.001). Single-center nonblinded trial. Primary assisted patency and incidence of infection and thrombosis were similar for both catheter types. The Palindrome catheter required less thrombolysis and achieved higher blood flow rates than the HemoStar catheter. These findings suggest that mechanical catheter design may improve catheter rheology, but does not affect risks for thrombosis and infection and hence catheter survival.American Journal of Kidney Diseases 04/2014; · 5.29 Impact Factor
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ABSTRACT: Citrate solution has been suggested as an effective and safe catheter lock in hemodialysis. However, whether a citrate lock is superior to a heparin lock in preventing catheter-related infections and maintaining catheter patency is inconclusive. A systematic review and meta-analysis was performed by searching in PubMed, EMBASE, Ovid, the Cochrane Library, and Web of Science databases and major nephrology journals. Patients receiving hemodialysis with central venous catheters. Randomized controlled trials comparing citrate locks with heparin locks in hemodialysis patients with central venous catheters. Locking central venous catheters with citrate locks. Primary outcomes include catheter-related bloodstream infection (CRBSI), exit-site infection, catheter removal for poor flow, and thrombolytic treatment. 13 randomized controlled trials (1,770 patients, 221,064 catheter-days) met the inclusion criteria. Pooled analyses found that citrate locks could significantly reduce the incidence of CRBSI (risk ratio [RR], 0.39; 95% CI, 0.27-0.56; P < 0.001). Subgroup analysis showed that antimicrobial-containing citrate locks (citrate + gentamicin, citrate + taurolidine, and citrate + methylene blue + methylparaben + propylparaben) were superior to heparin locks in the prevention of CRBSI (P < 0.001, P=0.003, and P=0.008, respectively), whereas citrate alone failed to show a similar advantage (P=0.2). Low- (1.04%-4%) to moderate-concentration (4.6%-7%) citrate locks were associated with decreased CRBSI incidence (P < 0.001 and P=0.003, respectively), but patients receiving high-concentration (30%-46.7%) citrate and heparin locks had similar incidences (P=0.3). The incidence of bleeding episodes (RR, 0.48; 95% CI, 0.30-0.76; P=0.002) was significantly lower in patients receiving citrate locks, whereas both groups were similar in terms of exit-site infection (P=0.2), catheter removal for poor flow (P=0.9), thrombolytic treatment (P=0.8), all-cause death (P=0.3), catheter thrombosis (P=0.9), mean catheter duration (P=0.2), CRBSI-free catheter survival (P=0.2), and catheter-related readmission (P=0.5). All studies used in the meta-analysis were performed in Western countries. The applicability of our findings to other regions remains to be clarified. An antimicrobial-containing citrate lock is better than a heparin lock in the prevention of catheter-related infection, while citrate alone fails to show a similar advantage. Citrate locks of low to moderate concentrations, rather than high concentration, were superior to heparin locks in preventing CRBSI. Citrate locks also might decrease bleeding episodes. No difference has been identified in the efficacy to prevent exit-site infection or preserve catheter patency between citrate and heparin locks.American Journal of Kidney Diseases 10/2013; · 5.29 Impact Factor
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ABSTRACT: Hemodialysis catheter-related bloodstream infections are potentially devastating, leading to increased morbidity, mortality, and cost of care. Prospective studies published over the past 15 years shed light on the pathogenesis of these infections. The data suggest that the intraluminal microbial colonization of hemodialysis catheters often precedes bloodstream infection. This finding supports strategies aimed at preventing or eradicating intraluminal colonization.Kidney International advance online publication, 8 January 2014; doi:10.1038/ki.2013.527.Kidney International 01/2014; · 8.52 Impact Factor