Decreasing Catheter Risk

Dialysis catheters play an important role in the provision of hemodialysis because they can provide immediate access for emergent dialysis and alternatives for patients with inadequate vasculature or medical conditions that preclude alternative access. Ideally catheters function as a short-term bridge to AV fistula or AV graft placement. Unfortunately, catheter use is often prolonged even when not medically necessary. In 2004, 63% of patients maintained on hemodialysis for <0.5 years, 36% on dialysis 0.5-0.9 years and 26% of patients on hemodialysis for 1-1.9 years were dialyzed via a catheter . 17]. This occurred despite the fact that over two thirds of catheter patients have adequate vessels for alternative access placement [18] and that catheter patients have almost double the mortality risk of AV fistula or AV graft patients [1,2].

The standard approach to decrease catheter complications is alternative access placement. Patients who change from a catheter to an alternative access benefit from a 52-60% reduction in their mortality risk (RR = 0.40 case-

mix adjustment, 0.48 baseline covariates adjustment, RR = 0.41 baseline covariates and follow-up adjustment) [19]. One recent report demonstrated that a systematic program of education and mapping followed by AV fistula creation successfully converted 57.9% (70/121, intention to treat) of all catheter patients and 81.4% (70/81) of patients who agreed to venous mapping to a functioning alternative access [18]. An alternative approach is to make catheters safer by decreasing the bacteremia risk. In one report, mortality decreased by 76% and hospitalization for catheter-related bacteremia decreased by 63% with the routine application of an antiseptic/antimicrobial solution (polysporin) at the catheter exit site [20]. Similar reductions in bacteremia have been reported with the use of muperacin ointment. Antimicrobial catheter lock solutions which decrease or prevent the formation of biofilm are also effective. Studies using citrate, taurolidine, gentamycin/heparin, gentamycin/EDTA have reported up to 76-93% reductions in catheter-related bacteremia [21]. Many of these solutions require further research or are not routinely available in the US. However, few facilities have tested or utilized these approaches even when available.

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