Efficacy of Tissue Plasminogen Activator for Thrombolysis in Central Venous Dialysis Catheters

Background:  Low blood flow is a frequent complication of central‐vein (CV) dialysis catheters. Since thrombotic occlusion accounts for many cases of reduced blood flow, it is common practice to administer empiric thrombolytic therapy in an attempt to restore catheter patency and improve function.
Methods:  We prepared tissue plasminogen activator (tPA) from 50 mg lyophilized powder, which was diluted (1 mg/mL) in sterile water for injection. A volume of 1 mL was frozen in 3 cc polystyrene syringes at −20 °C and thawed at room temperature when needed. tPA was then administered into the arterial and venous ports of the central venous catheter in a volume equal to the manufacturer's stated luminal volume and was allowed to dwell for 30 minutes.
Results:  tPA was administered 62 times in 25 patients with 30 catheters (11 Tesio, 17 PermCath, 2 Shiley) for treatment of low blood flow (pump speed < 250 mL/min). Complete restoration of patency was achieved in 23 episodes (mean blood flow pre‐tPA 130 mL/min; post‐tPA 320 mL/min); partial restoration of patency was achieved in 20 episodes (mean blood flow pre‐tPA 69 mL/min; post‐tPA 233 mL/min). tPA was just as likely to be effective in patients with complete catheter occlusion (i.e., no blood flow) as it was when some initial blood flow was present. Nineteen episodes failed to respond to tPA. These episodes occurred in 13 catheters, 12 of which ultimately underwent radiologic evaluation; an extraluminal cause for low blood flow was found in all 12 catheters (6 malpositioned, 6 fibrin sheaths).
Conclusions:  tPA at a dose of 1 mg/mL is effective for restoring patency in CV dialysis catheters. Failure to respond to tPA strongly suggests an extraluminal cause of catheter malfunction.     

Catheter‐related bacteremia and mortality in frequent nocturnal home hemodialysis

Frequent nightly home hemodialysis (NHHD) has emerged as an attractive alternative to thrice weekly in‐center hemodialysis, albeit with preponderant long‐term hemodialysis catheter used. Sixty‐three NHHD patients from University of Virginia Lynchburg Dialysis Facility were matched 1:2 with 121 conventional hemodialysis patients admitted to Fresenius Medical Care North America facilities from January 1, 2007 to December 31, 2010. Matching considered age (± 5 years), gender, race, dialysis vintage, and diabetes. The primary end‐point was the combined incidence of bacteremia/sepsis, for up to 20 months or upon changing to a fistula/graft (with catheter removal), transferring to peritoneal dialysis (PD), or at the time of kidney transplant or death. No significant differences were observed in rate of fistula/graft conversion, transfer to PD, transplant, or death between NHHD and in‐center hemodialysis (IHD) groups. For the first catheter used, the rate of catheter‐related sepsis was not significantly different between the NHHD (1.77 per 100 patient months) and IHD (2.03 per 100 patient months; P = 0.21). Combining all catheters, the rate of bacteremia/sepsis per 100 patient months in the NHHD group was 1.51 and in the IHD group was 2.01 (P = 0.35). Median catheter lifespan for the first catheter was 5.6 (1.7～19.0) for NHHD and 4.6 (2.7～7.8) for the IHD group (P = 0.64), and for all catheters used was 5.2 (Q1～Q3 = 1.5～15.2) months in NHHD group, and 4.1 (2.0～6.8) months in IHD group (P = 0.20). The rate of bacteremia and death is not different for up to 20 months in catheter users who dialyze via frequent NHHD vs. thrice weekly IHD.     

Low dose heparin lock (1000 U/mL) maintains tunnelled hemodialysis catheter patency when compared with high dose heparin (5000 U/mL): A randomised controlled trial

Introduction Heparin is commonly used after hemodialysis treatments as a locking solution to prevent catheter thrombosis. The comparative efficacy and safety of different heparin concentrations to maintain catheter patency has been previously reported in retrospective studies. We conducted a prospective, randomised, controlled study of 1000 U/mL heparin (low dose) versus 5000 U/mL heparin (high dose) locking solution to maintain patency of tunnelled catheters. Methods One hundred patients receiving chronic, unit‐based hemodialysis with newly placed tunnelled hemodialysis catheters (less than 1 week) were randomly assigned to either a low dose (n = 48) or high dose heparin (n=52). The primary intention‐to‐treat analysis examined time to malfunction in both groups over a 90 day period. A secondary analysis compared baseline patient characteristics in relation to catheter malfunction. Findings Overall rate of catheter patency loss was 32% of catheters by 90 days. There was no significant difference in time to malfunction of catheters locked with low dose or high dose heparin (P = 0.5770). Time to catheter malfunction was not associated with diabetic, hypertensive or smoking status. There was no difference in mean delivered blood flow rate, venous and arterial pressure, and dialysis adequacy between low dose and high dose groups. No patient suffered a hemorrhagic complication requiring hospitalisation during the study period. Discussion Low dose heparin is adequate to maintain tunnelled hemodialysis catheter patency when compared with high dose heparin. The study also suggests that there is no relationship between catheter malfunction and diabetic, hypertensive or smoking status.     

Comparison of side hole versus non side hole high flow hemodialysis catheters

Current literature suggests that side holes may be detrimental to dialysis catheter performance. Today, these catheters are primarily available with side holes. The purpose of this study was to compare flow rates, infection rate, and survival of side hole vs. non side hole hemodialysis catheters. Over a 16-month period patients were arbitrarily assigned to either a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter with side holes or a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter without side holes ("non side hole catheters"). We performed a retrospective analysis of catheter flow rates, patency, catheter survival, and catheter-related infections. Information was gathered for the life of the catheter or up to 28 weeks. A total of 54 patients were enrolled in the study. Thirty-seven of 54 (68%) patients received a catheter with side holes for a total of 3,930 catheter days and 17/54 (32%) received a similar catheter without side holes for a total of 2,188 catheter days. Catheter infection necessitating removal of the catheter occurred in 10/37 catheters with side holes and 1/17 without side holes. Infection rates per 1,000 catheter days were 2.545 with side holes and 0.254 without side holes (p<0.001). Slightly improved catheter survival (p<0.05) was recorded with the non side hole catheters. No insertion complication (e.g., air embolization, bleeding, or kinking) occurred with either catheter. One catheter without side holes had to be repositioned 5 days after insertion because of poor flows. No significant difference was recorded in mean blood flow rates between the catheters. Results indicate reduced catheter infection rate in hemodialysis patients with the use of non side hole dual lumen tunneled cuffed catheters.     

Risk of major depression in patients with chronic renal failure on different treatment modalities: A matched‐cohort and population‐based study in Taiwan

The influence of different treatment modalities on the risk of developing major depression in patients with chronic renal failure (CRF) is not well understood. We aimed to explore the incidence of major depression among patients with CRF who were on different dialysis modalities, who had received renal transplantation (RT), and those who had not yet received any of the aforementioned renal replacement therapies. We conducted a population‐based retrospective cohort study using a national health insurance research database. This study investigated 89,336 study controls, 17,889 patients with chronic kidney disease on conservative treatment, 3823 patients on hemodialysis (HD), 351 patients on peritoneal dialysis (PD), and 322 patients who had RT. We followed all individuals until the occurrence of major depression or the date of loss to follow‐up. The PD group had the highest risk (hazard ratio [HR] 2.43; 95% confidence interval [CI] 1.26–4.69), whereas the RT group had the lowest risk (HR 0.18; 95% CI 0.03–1.29) of developing major depression compared with the control group. Patients initiated on PD had a higher risk of developing major depression than patients initiated on HD (pairwise comparison: HR 2.20; 95% CI 1.09–4.46). Different treatment modalities are associated with different risks of developing major depression in patients with CRF. Among renal replacement therapies, patients who have had RT have the lowest risk of developing major depression. Patients who initiate renal therapy on PD may have a higher risk of major depression compared with patients who initiate renal therapy on HD.     

Dialysis access venous stenosis: Treatment with balloon angioplasty 30‐second vs. 1‐minute inflation times

Percutaneous balloon angioplasty is the standard of care in the endovascular treatment of dialysis access venous stenosis. The significance of balloon inflation times in the treatment of these stenoses is not well defined. Our objective was to examine the outcomes of 30‐second vs. 1‐minute balloon inflation times on primary‐assisted patency of arteriovenous fistulae and grafts. Using a prospectively collected vascular access database, we identified a total of 75 patients referred for access dysfunction during a 5‐year period. These patients received 223 interventions (178 with 30‐second inflations and 45 with 1‐minute inflations). We compared primary‐assisted patency during the subsequent 9 months across groups defined by inflation times. Demographics and baseline characteristics were similar across groups. Immediate technical success and patency in the first 3 months were similar across groups (hazard ratio [HR] = 0.86; 95% confidence interval [CI]: 0.34–2.20). After 3 months, however, a 1‐minute inflation time was associated with greater incidence of access failure (adjusted HR [aHR] = 1.74; 95% CI: 1.09–2.79). Other predictors of access failure included age over 60 (aHR = 1.02; 95% CI: 1.01–1.04), central location of the lesion (aHR = 2.49; CI: 1.27–4.89), and three or more prior procedures (aHR 2.48; CI: 1.19–5.16). Our data suggest that shorter balloon inflation times may be associated with improved longer term access patency, although the benefit was not observed until after 3 months. Given the increasing demands of maintaining access patency in the era of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and Fistula First, the role of angioplasty times requires further study.     

Maintenance of blood flow rate on dialysis with self‐centering CentrosFLO catheter: A multicenter prospective study

Introduction Chronic central venous catheters (CVC) for dialysis lose patency and deliver lower blood flow over time, often due to fibrous sheathing that covers the lumen tips. The CentrosFLO central venous catheter has a shape that directs the arterial and venous tips away from the walls of the vena cava and right atrium, making sheathing of the tips less likely. Methods A prospective, multicenter, single arm, non‐controlled, observational study was conducted at eight sites in the United States. All consenting dialysis patients receiving CentrosFLO catheters through the right or left internal jugular veins were accepted in the study, as long as the catheter was expected to be used for 45 days and was not an over‐the‐wire replacement for a previous CVC. Data were automatically collected on initial and average dialysis blood flow rate and initial arterial and venous pressures, for up to 26 weeks of dialysis therapy. Findings 75 patients were enrolled. Kaplan‐Meier analysis indicated that 87% of patients maintained blood flow rate over 300 mL/min throughout 26 weeks of follow‐up. There was no decline in average dialysis blood flow rate and no significant change in hydraulic resistance of the arterial or venous lumens of the catheters during the study. Discussion The CentrosFLO catheter demonstrates long term patency with good flow rates on dialysis, which, by comparison with previous studies, shows a clinically significant improvement in blood flow rate vs. other catheters. Stable hydraulic resistance of the catheter lumens showed no evidence of tip encroachment by fibrous sheaths.     

Factors predicting failure of AV “fistula first” policy in the elderly

An arteriovenous fistula (AVF) is the preferential hemodialysis (HD) access. The goal of this study was to identify factors associated with pre‐dialysis AVF failure in an elderly HD population. We used United States Renal Data System + Medicare claims data to identify patients ≥67 years old who had an AVF as their initial vascular access placed pre‐dialysis. Failure of the AVF to be used for initial HD, was used as the outcome. Logistic regression model was used to identify factors associated with AVF failure. The study cohort consisted of 20,360 subjects (76.2 ± 6.02 year old, 58.5% men). Forty‐eight percent of patients initiated dialysis using an AVF, while 52% used a catheter or an AVG. The following variables found to be associated with AVF failure when an AVF was created at least 4 months pre‐HD initiation: older age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00–1.02), female gender (OR 1.69; 95% CI 1.55–1.83), black race (OR 1.41; 95% CI 1.26–1.58), history of diabetes (OR 1.22; 95% CI 1.06–1.39), cardiac failure (OR 1.26; 95% CI 1.15–1.37), and shorter duration of pre–end‐stage renal disease (ESRD) nephrology care (OR for a nephrology care of less than 6 months prior to ESRD of 1.22 compared with a pre‐ESRD nephrology follow up of more than 12 months; 95% CI 1.07–1.38). OR for AVF failure for the entire cohort showed similar findings. In an elderly HD population, there is an association of older age, female gender, black race, diabetes, cardiac failure and shorter pre‐ESRD nephrology care with predialysis AVF failure.     

Relation between Access-Related Infection and Preinfection Serum Albumin Concentration in Patients on Chronic Hemodialysis

Background: Hemodialysis (HD) access‐related infection is a major cause of morbidity and mortality in HD patients. We tested whether hypoalbuminemia is a risk factor for HD access infection and whether mortality of HD catheter infection is affected by removal of the infected catheter. Methods: We analyzed the records of 87 patients on chronic HD who were hospitalized for HD access‐related infection. We obtained data on age, sex, preinfection serum albumin level, comorbidities, complications, infecting organism, type of infection, mode of management, and mortality. We compared preinfection serum albumin levels in 79 patients with HD access infection with the serum albumin levels of 198 control patients on chronic HD without HD access infection admitted to the hospital during the same time for other reasons. In the HD catheter infection subgroup, we compared mortalities between patients treated with catheter removal plus antibiotics as the primary mode of management and those treated initially with antibiotics alone. Results: Preadmission serum albumin level was lower in the HD access infection group (2.4 ± 0.6 g/dL) than in the control group (3.2 ± 0.6 g/dL, P < 0.0001). Logistic regression identified preadmission serum albumin level as a strong independent predictor of HD access infection. In a logistic regression model, with age, sex, HIV status, diabetes, and type of HD vascular access (excluding arterovenous fistula) as the covariates, the odds ratio of HD access infection was 9.8 (95% confidence interval [CI] 4.9–19.7) for a serum albumin level ≤ 3.0 g/dL (P < 0.0001), 10.4 (95% CI 4.97–21.6) for a serum albumin level ≤ 2.5 g/dL (P < 0.0001), and 28.0 (95% CI 5.8–135.9) for a serum albumin level ≤ 2.0 g/dL (P < 0.0001). Case mortality was 25.0% (4/16) in patients with tunneled HD catheter infection initially treated with antibiotics alone and 2.8% (2/71) in those treated with catheter removal plus antibiotics at the time of presentation (P = 0.0096). Conclusion: Hypoalbuminemia is associated with increased risk of HD access infection. Treatment of HD access infection with antibiotics alone is associated with increased risk of death.     

Single‐lumen tunneled catheter: An old but useful option

We report a case of long‐term uneventful catheter use in a patient with previous recurrent vascular access dysfunction and infection. A single‐lumen tunneled catheter was inserted into the left internal jugular vein after a failed attempt of dual‐lumen permanent catheter placement. The follow‐up since device implantation has exceeded 5 years without any complications related to vascular access.     

Usefulness of assisted procedures for arteriovenous fistula maturation without compromising access patency

Introduction: To increase the rate of arteriovenous fistula (AVF) use, assisted procedures for immature AVF have been strenuously performed. However, this is controversial in that an AVF matured by these assisted procedures may require more frequent intervention to maintain its patency, and have decreased long‐term patency. Methods: Eighty four AVFs that were matured with assisted maturation procedures and 266 AVFs that matured spontaneously without intervention, created between November 2009 and March 2013 from the hemodialysis (HD) vascular access (VA) cohort, were compared retrospectively and we also investigated the factors that may influence AVF long‐term patency. Median follow‐up was 26.8 months (interquartile range, 6.6–45.0 months). Findings: Access survival did not differ between AVFs matured by assisted procedures and spontaneously mature AVFs (P = 0.29). In multivariate Cox regression analysis of AVF survival, age (HR, 1.029; 95% CI, 1.004–1.056; P = 0.024), maturation without assisted procedures 4–6 weeks after AVF creation (HR, 0.233; 95% CI, 0.107–0.506; P < 0.001), and AVF thrombosis (HR, 26.511; 95% CI, 10.986–63.978; P < 0.001) were significantly associated with AVF survival. Performance of assisted procedures to induce AVF maturation did not influence AVF survival (HR, 0.437; 95% CI, 0.191–1.002; P = 0.05). Discussion: Our results support that idea that assisted maturation procedures can ensure the success of immature AVF without compromising long‐term patency. These procedures can be considered more positively for increasing AVF use for VA placement in HD patients.     

Efficacy of preventing hemodialysis catheter infections with citrate lock

Prevalent use of tunneled dialysis catheters can reach 30%. Infection remains the most serious catheter‐related problem. Catheter locks are increasingly used for prevention, but are not yet recommended either by the Food and Drug Association or European Medicines Agency, on the basis of increasing bacterial resistance or lock toxicity. The aim was to test safety and effectiveness of citrate. A prospective, interventional study was conducted to assess the safety and efficacy of a 30% citrate lock in preventing catheter‐related bacteremia (CRB). A total of 157 prevalent tunneled catheters were locked with citrate and prospectively followed during a 1‐year period. The primary endpoint was first CRB diagnosed according to two of the diagnostic criteria for Catheter Infection of Centers for Disease Control and Prevention (CDC), namely definite and probable infection. The CDC criterion of possible but not proved infection was not considered. This citrate lock cohort (n = 157) had 10 episodes of CRB. We observed 0.49 CRB episodes/1000 patient‐days and the mean infection‐free catheter day was 130.6 ± 100.9. No clinically relevant adverse events were observed. No proved tunnel or exit site infection was observed and no patients died because of CRB. Catheter obstruction episodes were reported on 69 occasions out of 14 catheters. These results were compared with an historical cohort from a previous study of catheter locking with low‐dose gentamicin and did not show significant difference in efficacy. Citrate lock is effective in preventing CRB. No toxicity was observed. The use of citrate lock may have advantages over antibiotic locks: No reported bacterial resistance, lower industrial cost, and less manipulation.     

Concentrated Sodium Citrate (23%) for Catheter Lock

For chronic central venous dialysis catheters, the standard method for maintaining catheter patency between treatments is to instill (lock) catheters with 5000 – 10 000 units of heparin in each lumen. Sodium citrate (citrate) is an anticoagulant with intrinsic antibacterial activity (at 20% concentration or higher). Citrate has only transient anticoagulant effects if accidentally infused to the patient. Prior studies of citrate as a catheter lock solution have utilized citrate concentrations of 1% in combination with 27 mg/mL gentamicin. We changed clinical protocols for catheter locks using various solutions, including concentrated citrate, in a dialysis unit with 50% of patients having chronic central venous catheters [40 catheters total, mostly Ash Split Cath (Medcomp, Harleysville, PA, U.S.A.) but some Tesio (Medcomp) and Hickman (BARD, Salt Lake City, UT, U.S.A.) catheters]. At 3‐ to 4‐month intervals, the standard catheter lock solution for the unit was varied on the following schedule: heparin; 10% citrate with 3 mg/mL gentamicin; 20% citrate with 3 mg/mL gentamicin; heparin; and 23% citrate. Catheters were not routinely removed during treatment of bacteremia. Incidence of bacteremia in patients with catheters using heparin as catheter lock was 4.32 episodes per 3000 patient‐days (equivalent to percent of patients with catheters having bacteremia per month). The incidence of bacteremia decreased to 1.68 using 20% citrate/gentamicin as catheter lock (p < 0.05) and to 0% with 47% citrate (p < 0.05). Incidence of bacteremia increased on return to heparin and decreased again with use of 23% citrate to 1.79 (p < 0.05). Use of urokinase for occluded catheters also significantly decreased with citrate during the time that it was available (p = 0.02). Life table analysis indicated an 83% survival of Ash Split Cath catheters at 1 year, in this unit. Concentrated citrate is an effective catheter lock solution that may provide prolonged central venous catheter use with a diminution in catheter‐related infections and occlusion.     

Lower C‐reactive protein and better hemodialysis survival are associated with regular exercise activity: Longitudinal outcomes from the ACTIVE‐ADIPOSE special study

Introduction Cross‐sectional and longitudinal studies in the general population have shown that a physically active lifestyle may have anti‐inflammatory properties, but evidence from studies conducted with maintenance hemodialysis (HD) patients is limited. Methods A multicenter prospective cohort of 755 HD participants aged 20–92 was evaluated in a USRDS special study 2009–2013. Kilocalories/week (kcal/week) of leisure time physical activity (LTPA) was estimated from the Minnesota Leisure Time Activity questionnaire. Predialysis serum samples were obtained concurrent with LTPA report date. Generalized estimating equations (GEE) examined association of participants’ LTPA and log‐normalized CRP across 24 months. Cox proportional hazards models investigated LTPA and survival over a median follow‐up of 718 days. Findings Baseline median CRP concentration was lower for participants with 500+ kcal/week LTPA vs. those with <500 kcal/week LTPA (3.4 mg/L vs. 4.6 mg/L; P = 0.03). Participants who reported lower LTPA (<500 kcal/week) at both baseline and 12 months had a borderline significant increase in CRP concentration (within‐group change 4.8 [1.9–10.4] to 5.8 [1.6–15.7]; P = 0.08). Lower LTPA was associated with higher log CRP over 24 months in adjusted GEE analyses (β coefficient = 0.16 [95% CI 0.02–0.31]; P = 0.03). 67/364 (18%) and 43/391 (11%) deaths occurred, respectively, among participants reporting <500 vs. 500+ kcal/week LTPA [adjusted mortality hazard ratio 1.63 (CI, 1.07, 2.47)]. Discussion The data suggest that increased estimated levels of LTPA, a physical activity/exercise opportunity widely applicable to HD patients, may be associated with lower CRP concentration as well as better survival outcome.     

Alteplase vs. urokinase for occluded hemodialysis catheter: A randomized trial

Introduction Thrombosis of tunneled central venous catheters (CVC) in hemodialysis (HD) patients is common and it can lead to the elimination of vascular sites. To compare the efficacy of alteplase vs. urokinase in reestablishing adequate blood flow through completely occluded vascular catheters. Methods In this randomized study, patients with completely occluded tunneled HD catheters received 40 minutes intracatheter dwell with alteplase (1 mg/mL) or urokinase (5000 IU/mL). Primary endpoint was the proportion of patients with occluded catheters achieving post‐thrombolytic blood flow of ≥250 mL/min. Safety endpoints included the incidence of hemorrhagic and infectious complications. Findings Eligible adult patients (n = 100) were treated with alteplase (n = 44) or urokinase (n = 56). The two groups were similar in gender (male: 51.8% vs. 56.8%, P = 0.35), age (60 ± 12 vs. 59 ± 13 years, P = 0.71), time on dialysis (678 ± 203 vs. 548 ± 189 days, P = 0.77), diabetes and cardiovascular disease (55.6% vs. 70.4%, P = 0.08 and 17.8% vs. 22.7%, P = 0.38, respectively), jugular vein as main vascular access (54.8% vs. 62.5%, P = 0.57), and time of CVC (278 ± 63 vs. 218 ± 59 days, P = 0.67). Primary success with alteplase and urokinase occurred in 42/44 (95%) vs. 46/56 (82%), P = 0.06. Success was not achieved after the second dose of alteplase and urokinase in 1 and 7 cases, respectively (2% vs. 12%, P = 0.075). Serious adverse effects were not observed in both groups. There was no difference between the two groups in infectious complications (P = 0.94). Discussion Alteplase and urokinase are effective thrombolytic agents for restoring HD catheter patency. Our study has revealed a likely slight superiority of alteplase over urokinase for unblocking central lines, but which has enrolled too few patients to be able to detect a difference of this size.     

Prevention of Damage to Cuffed Catheters

Cuffed catheters, although not ideal for long-term use, are now used more frequently due to an increase in the aging population, in whom the vessels are not suitable for either arteriovenous fistulas or polytetrafluoroethylene (PTFE) grafts. Infections and thrombosis remain the major causes for removal or change of catheters. We recently identified eight catheter defects that required replacement of catheters. Of these, two were due to patient negligence: one catheter was accidentally severed while the patient was shaving; the other was snipped during a haircut. One was believed to have a manufacturing defect. One catheter sustained needle-prick damage near the hub while irrigating the catheter. Two catheters were lost due to needle pricks during skin closure, and one catheter sustained similar damage while fixing the suture wing to the skin. The other two were damaged by suture material slicing through the lumen of the catheter as it expanded due to increased blood flow during repeated dialyses. Importantly, several of these injuries to the catheters were not immediately obvious and were detected only after repeated use of the catheters. Delayed bleeding of cuffed catheters necessitating change or removal has not been reported. Such bleeding may be due to manufacturing defects, patient carelessness, or iatrogenic causes. Avoiding the use of sutures can minimize the latter. Skin closure strips and a double transparent dressing may serve the same purposes, such as securing the catheter and aiding wound healing. In addition, these dressings have the added advantage of being waterproof, bacteria-proof, and cost effective.     

Daptomycin antibiotic lock therapy for hemodialysis patients with Gram‐positive bloodstream infections following use of tunneled,cuffed hemodialysis catheters: retrospective single center analysis

Catheter‐related blood stream infection (CRBSI) is a major complication in hemodialysis patients. We assessed the efficacy of systemic daptomycin (DPT) plus DPT antibiotic lock therapy (DPT‐ALT) for catheter salvage in patients with Gram‐positive CRBSIs. This is a retrospective study of hemodialysis patients with tunneled and cuffed hemodialysis catheters. All patients were from a single institution in Taipei and received systemic DPT plus DPT‐ALT for the treatment of Gram‐positive CRBSI. Successful resolution of CRBSI was implemented. Resolution of fever within 48 hours, negative result of repeated blood cultures after resolution of fever, no clinical evidence of CRBSI relapse and no need for catheter removal were measured. Fifteen hemodialysis patients received DPT‐ALT for CRBSI, nine with coagulase‐negative Staphylococcus (CONS), two with methicillin‐resistant Staphylococcus aureus (MRSA), three with methicillin‐sensitive Staphylococcus aureus (MSSA) and one with polymicrobial infections. Systemic DPT plus DPT‐ALT cured 11 patients (73.3%). Treatment failed in all three MRSA cases (two with MRSA and one with MRSA + Enterococcus faecalis). Retrospective design and small sample size were the limitations of this study. Systemic DPT plus DPT‐ALT appears to be a promising treatment for CRBSI from CONS and MSSA, but not for MRSA CRBSI. Systemic DPT plus DPT‐ALT should be considered for patients with CRBSIs caused by certain species.     

Catheter‐related fungal endocarditis caused by Candida parapsilosis in a hemodialysis patient

Fungal endocarditis (FE) is commonly regarded as a rare but fatal disease. The incidence of infective endocarditis (IE) in hemodialysis (HD) patients is thought to be obviously higher than that in the general population. Moreover, IE occurs more likely in HD patients with catheters. With the increase of HD population and extensive use of catheters in HD patients, FE, as a special form of IE, may increase and bring new challenges to clinicians. We reported a case of FE associated with catheter infection in a 44‐year‐old woman on HD. The risk factors and treatment strategies of FE in HD patients were discussed.