J YAXLEY1,2,3, J KURTKOTI2,3, L STOCKWELL3
1Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia , 2Griffith University School of Medicine, Gold Coast, Queensland, Australia, 3Department of Nephrology, Gold Coast University Hospital, Gold Coast, Australia ,
Aim: To evaluate local practices and the utility of common interventions for tunnelled haemodialysis catheter dysfunction.
Background: Catheter dysfunction is a common problem, usually as a result of intraluminal thrombosis. Although scientific evidence is lacking, protocols recommend various conservative measures prior to catheter replacement, such as chest radiography to confirm line position, evaluating fluid status to avoid hypovolaemia, and thrombolytic therapy.
Methods: We performed a retrospective chart review of all patients receiving intra-catheter thrombolysis for catheter dysfunction, over 12 months from August 2018 in our metropolitan hospital network. After presenting initial findings to our renal department and instituting a protocol, identical data were prospectively audited for a further 6 months.
Results: Thrombolytic therapy was prescribed on 66 occasions over 12 months. Adherence to general guideline recommendations was low. Prior to thrombolysis, chest x-ray and fluid status was reviewed in only 39% and 18% of patients respectively. Objective criteria defining actual catheter dysfunction was documented in only 44% of patients. Overall, thrombolysis successfully reversed catheter dysfunction in 56% of cases. Chest radiograph acquisition, volume status optimisation, and documented presence of actual dysfunction were each associated with greater thrombolysis efficacy. Median catheter survival following thrombolysis was 40 days, and catheter patency at 3 months was 31%. Following our staff education session thrombolytic prescriptions declined by more than 50%. This was accompanied by wider use of protocoled measures and better thrombolysis efficacy. Overall success increased to 75% with a median catheter survival of 75 days.
Conclusion: Thrombolytic therapy successfully remediates haemodialysis catheter dysfunction in the majority of cases. Within the limits of a chart review design our findings indicate that observation of routine non-pharmacological measures and confirmation of catheter dysfunction by objective numerical criteria prior to its use are associated with improved efficacy.
Dr Julian Yaxley is a nephrology advanced trainee at Princess Alexandra Hospital in Brisbane. He has an interest in critical care and interventional nephrology.