Handbook of Dialysis Fifth Edition by Daugirdas.pdf

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Dialysis Edited by

John T. Daugirdas, MD, FACP, FASN Clinical Professor of Medicine University of Illinois at Chicago Chicago, Illinois

Peter G. Blake, MB, FRCPC, FRCPI Professor of Medicine Western University London, Ontario, Canada

Todd S. Ing, MBBS, FRCP Professor Emeritus of Medicine Loyola University Chicago Maywood, Illinois

Acquisitions Editor: Julie Goolsby Product Development Editor: Leanne Vandetty Editorial Assistant: Brian Convery Production Project Manager: Bridgett Dougherty Design Coordinator: Holly Reid McLaughlin Manufacturing Coordinator: Beth Welsh Prepress Vendor: S4Carlisle Publishing Services Fifth Edition Copyright © 2015 Wolters Kluwer Health Copyright © 2007 Lippincott Williams & Wilkins, a Wolters Kluwer business. Copyright © 2001 Lippincott Williams & Wilkins. Copyright © 1994, 1988 by J. B. Lippincott. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations ­embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the abovementioned copyright. To request permission, please contact Wolters Kluwer Health at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at ­[email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in the US Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and U.S. Virgin Islands. Library of Congress Cataloging-in-Publication Data Handbook of dialysis / [edited by] John T. Daugirdas, Peter G. Blake, Todd S. Ing. — Fifth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-4429-1 (paperback) I. Daugirdas, John T., editor. II. Blake, Peter Gerard, 1956- , editor. III. Ing, Todd S., editor. [DNLM: 1. Renal Dialysis—Handbooks. WJ 39] Proudly sourced and uploaded by [StormRG] RC901.7.H45 Kickass Torrents | TPB | ET | h33t 617.4’61059—dc23 2014029014 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author(s), editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

To Stanislovas Maˇciulis, MD—a beloved ­grandfather never met who continues to guide and inspire. (JTD) To my wife Rose and to my sons, Matthew and Andrew—the three most important people in my life. (PB) To Oliver M. Wrong, MD, FRCP, my exemplary mentor. (TSI)

Anil K. Agarwal, MD, FASN, FACP

Sudhir K. Bowry, PhD

Suhail Ahmad, MD

Deborah Brouwer-Maier, RN, CNN

Professor of Medicine Ohio State University Columbus, Ohio

Professor of Medicine University of Washington Seattle, Washington

Michael Allon, MD

Fresenius Medical Care Bad Homburg, Germany

Director of Dialysis Access ­Initiatives Fresenius Medical Services Philadelphia, Pennsylvania

Professor of Medicine University of Alabama at ­Birmingham Birmingham, Alabama

Bernard Canaud, MD, PhD

Arif Asif, MD, FASN

Ralph J. Caruana, MD, MBA

­ rofessor of Medicine P Albany Medical College Albany, New York

André Luis Balbi, MD

Assistant Professor of Medicine São Paulo State University—UNESP Botucatu, São Paulo, Brazil

Joanne M. Bargman, MD, FRCPC Professor of Medicine University of Toronto Toronto, Ontario, Canada

Susan E. Bentley RD, MBA Fresenius Medical Care Waltham, Massachusetts

Peter G. Blake, MB, FRCPC, FRCPI Professor of Medicine Western University London, Ontario, Canada

Neil Boudville, MBBS, FRACP

Emeritus Professor of Nephrology Montpellier University I Montpellier, France Professor of Medicine University of Central Florida Orlando, Florida

Elliot Michael Charen, MD Instructor in Medicine Icahn School of Medicine at Mount Sinai New York, New York

Horng Ruey Chua, MMed, MRCP Assistant Professor of Medicine National University of Singapore Republic of Singapore

Scott D. Cohen, MD, MPH, FASN Associate Professor of Medicine George Washington University Washington, District of Columbia

Daniel W. Coyne, MD Professor of Medicine Washington University St. Louis, Missouri

Senior Lecturer in Renal Medicine University of Western Australia Crawley, Australia vii

viii Contributing Authors

John H. Crabtree, MD, FACS

Visiting Clinical Faculty Harbor-University of California Los Angeles Medical Center Torrance, California

Daniel Cukor, PhD

Associate Professor of Psychiatry SUNY Downstate Medical Center Brooklyn, New York

John T. Daugirdas, MD, FACP, FASN Clinical Professor of Medicine University of Illinois at Chicago Chicago, Illinois

Andrew Davenport, MA, MD, FRCP

Reader in Medicine and Nephrology University College of London London, United Kingdom

Fredric O. Finkelstein, MD

Clinical Professor of Medicine Yale University New Haven, Connecticut

Steven Fishbane, MD

Professor of Medicine Hofstra North Shore—Long Island Jewish School of Medicine Hempstead, New York

Marc Ghannoum, MD

Associate Professor of Medicine University of Montréal Montréal, Québec, Canada

Susan Grossman, MD

Associate Professor of Clinical Medicine New York College of Medicine Valhalla, New York

Nikolas B. Harbord, MD

James A. Delmez, MD Professor of Medicine Washington University St. Louis, Missouri

Assistant Professor of Medicine Icahn School of Medicine at Mount Sinai New York, New York

Sevag Demirjian, MD

Olof Heimbürger, MD, PhD

Assistant Professor of Medicine Cleveland Clinic Lerner College of Medicine Cleveland, Ohio

Department of Clinical Science, ­Intervention, and Technology Karolinska Institute Stockholm, Sweden

Peter B. DeOreo, MD, FACP

Joachim Hertel, MD, FACP

Clinical Professor of Medicine Case Western Reserve University Cleveland, Ohio

Lead Physician Greenville Kidney Care, LLC Greenville, South Carolina

Jose A. Diaz-Buxo, MD, FACP

Nicholas Hoenich, PhD

Interim Medical Office Liaison Renal Therapies Group Fresenius Medical Care NA Charlotte, North Carolina

Lecturer Newcastle University Newcastle upon Tyne, United ­Kingdom

Mary Ann Emanuele, MD

Professor of Medicine Loyola University Chicago Maywood, Illinois

Professor of Medicine Loyola University Chicago Maywood, Illinois

Nicholas Emanuele, MD

Priscilla How, PharmD, BCPS

Professor of Medicine Loyola University Chicago Maywood, Illinois

Assistant Professor Department of Pharmacy National University of Singapore Republic of Singapore

T. Alp Ikizler, MD

Professor of Medicine Vanderbilt University Nashville, Tennessee

Todd S. Ing, MBBS, FRCP

Professor Emeritus of Medicine Loyola University Chicago Maywood, Illinois

Arsh Jain, MD, FRCPC

Assistant Professor of Medicine Western University London, Ontario, Canada

Jameela Kari, CABP, MD, CCST, FRCPCH, FRCP (UK) Professor of Pediatrics King Abdul Azziz University Jeddah, Kingdom of Saudi Arabia

Paul L. Kimmel, MD, MACP, FASN Clinical Professor of Medicine George Washington University Washington, District of Columbia

Dobri D. Kiprov, MD, HP

Chief, Division of Immunotherapy California Pacific Medical Center San Francisco, California

Kar Neng Lai, MBBS, MD, DSc, FRCP, FRACP, FRCPath Professor Emeritus of Medicine University of Hong Kong Hong Kong, China

Derek S. Larson, MD

Nephrologist Missouri Baptist Medical Center St. Louis, Missouri

David J. Leehey, MD

Professor of Medicine Loyola University Chicago Maywood, Illinois

Joseph R. Lentino, MD, PhD Professor of Medicine Loyola University Chicago Maywood, Illinois

Philip Kam-Tao Li, MD, FRCP, FACP

Honorary Professor of Medicine Chinese University of Hong Kong Hong Kong, China

Robert M. Lindsay, MD, FRCPC, FRCP (Edin), FRCP (Glasg), FACP Professor of Medicine Western University London, Ontario, Canada

Francesca Mallamaci, MD Professor of Nephrology Ospedali Riuniti Reggio Calabria, Italy

Christopher McIntyre, MBBS, DDM Professor of Medicine Western University London, Ontario, Canada

Susan R. Mendley, MD

Associate Professor of Pediatrics and ­Medicine University of Maryland Baltimore, Maryland

Rajnish Mehrotra, MD, MS Professor of Medicine University of Washington Seattle, Washington

Stephen A. Merchant, PhD

Vice President and General Manager SORB Technology Division Fresenius Medical Care NA Oklahoma City, Oklahoma

Jennifer S. Messer, CHT, OCDT, CCNT

Clinical Education Specialist Department of Critical Care NxStage Medical, Inc. Lawrence, Massachusetts

Madhukar Misra, MD, FASN, FACP, FRCP (UK) Professor of Medicine University of Missouri Columbia, Missouri

Gihad E. Nesrallah, MD, FRCPC, FACP

Amber Sanchez, MD

Adjunct Professor of Medicine Western University London, Ontario, Canada

Assistant Clinical Professor of Medicine University of California, San Diego San Diego, California

Allen R. Nissenson, MD, FACP

Mark J. Sarnak, MD, MS

Emeritus Professor of Medicine University of California at Los Angeles Los Angeles, California Chief Medical Officer DaVita Healthcare Partners Inc. El Segundo, California

Jacqueline T. Pham, PharmD, BCPS

Adjunct Professor School of Nursing & Health Studies Georgetown University Washington, District of Columbia

Andreas Pierratos, MD, FRCPC Professor of Medicine University of Toronto Toronto, Ontario, Canada

Daniela Ponce, MD, PhD

Assistant Professor of Medicine São Paulo State University—UNESP Botucatu, São Paulo, Brazil

Charles D. Pusey, DSc, FRCP, FASN, FMCISci Professor of Medicine Imperial College London London, United Kingdom

Michael V. Rocco, MD, MSCE

Professor of Medicine and Public Health Sciences Wake Forest University Winston-Salem, North Carolina

Edward A. Ross, MD

Professor of Medicine University of Central Florida Orlando, Florida

Assistant Professor of Clinical Medicine University of Miami Miami, Florida

Professor of Medicine Tufts University Boston, Massachusetts

Hitesh H. Shah, MD

Associate Professor of Medicine Hofstra North Shore-Long Island Jewish School of Medicine Hempstead, New York

Richard A. Sherman, MD

Professor of Medicine Rutgers, The State University of New Jersey New Brunswick, New Jersey

Ajay Singh, MBBS, FRCP (UK), MBA Associate Professor of Medicine Harvard University Boston, Massachusetts

Stefano Stuard, MD

Director of Clinical Governance – NephroCare Fresenius Medical Care Bad Homburg, Germany

Rita S. Suri, MD, Msc, FRCPC, FACP Associate Professor of Medicine University of Montréal Montréal, Québec, Canada

Cheuk-Chun Szeto, MD, FRCP (Edin)

Senior Lecturer in Medicine Chinese University of Hong Kong Hong Kong, China

Boon Wee Teo, MB, BCh, BAO, B Med Sci, FACP, FASN Assistant Professor of Medicine National University of Singapore Republic of Singapore

Tran H. Tran, PharmD, BCPS

Assistant Clinical Professor St. John’s University College of ­Pharmacy and Allied Health ­Professions Queens, New York

Fresenius Medical Care Walnut Creek, California

Tushar J. Vachharajani, MD, FASN, FACP

Professor of Medicine Edward Via College of Osteopathic Medicine Spartanburg, South Carolina

Richard A. Ward, PhD

Professor of Nephrology (retired) University of Louisville Louisville, Kentucky (Nelson, New Zealand)

Daniel E. Weiner, MD, MS

James F. Winchester

Professor of Clinical Medicine Albert Einstein College of Medicine of Yeshiva University Bronx, New York

Steven Wu, MD, FASN

Assistant Professor of Medicine Harvard University Boston, Massachusetts

Alexander Yevzlin, MD

Associate Professor of Medicine University of Wisconsin Madison, Wisconsin

Carmine Zoccali, MD, FASN, FERA

Professor of Nephrology Director, Center for Clinical ­Physiology, Renal Diseases and ­Hypertension of the Italian ­Research Council Reggio Calabria, Italy

Associate Professor of Medicine Tufts University Boston, Massachusetts

We are very fortunate and honored to present this Fifth Edition of the Handbook of Dialysis to the nephrology community. It has been 7 years since the Fourth Edition; the long interval reflects the relatively slow, incremental nature of improvements that have occurred in dialysis therapy during that period. We continue with a strong international emphasis, referencing both KDOQI and KDIGO guidelines, and taking care to express laboratory m ­ easurements in both British Imperial and SI units. The chapter on online hemodiafiltration, a therapy still not available in the United States, has been maintained and updated. A chapter on sorbent dialysis, present in the first two editions of the Handbook, but removed from the third and fourth editions as use of the REDY system dwindled, has been reinstated and modernized, given the anticipated imminent release of new sorbent-equipped machines for both in-center and home hemodialysis. The hemodialysis vascular access section, which grew from one to two chapters between the third and fourth editions, has now expanded to four chapters, testifying to the importance of vascular access to overall hemodialysis patient care. In the peritoneal dialysis section, the ­access chapter was completely rewritten by a general surgeon with long experience and dedication in this area. Another completely ­rewritten chapter describes the growing use of acute peritoneal ­dialysis and “urgent start” PD. For both peritoneal dialysis and hemodialysis adequacy, fewer equations are used and, instead, analogies help explain key concepts. More emphasis is placed on dialysis time, frequency, ultrafiltration rate, and other supplementary metrics of adequacy, including doing dialysis the “European way.” To make room for expanded and additional chapters, a number of topics that were discussed in great detail in their own separate chapters in the Fourth Edition have been downsized and folded into other chapters; our goal was to maintain a pocket-sized book that focuses on frequently encountered clinical problems. As in previous editions, we have tried to maintain the unique character of the Handbook of Dialysis, aiming for a resource that will be useful to both new and experienced nephrology care providers to help them in their difficult job of assuring the best treatment for our patients.

We would like to thank the many chapter authors who agreed to write for the Handbook. The time demands on clinical nephrologists and other care providers continue to increase, and we greatly appreciate the willingness of our chapter authors to allocate precious time to share their insights and expertise. We would also like to recognize Aleksandra Godlevska for her beautiful modern art–inspired cover design.

John T. Daugirdas Peter G. Blake Todd S. Ing

C ontributing Authors Preface

PART I: CHRONIC KIDNEY DISEASE MANAGEMENT

1 Approach to Patients with Chronic Kidney Disease, Stages 1–4

2 Management of CKD Stages 4 and 5: Preparation for Transplantation, Dialysis, or Conservative Care

Ajay Singh and Jameela Kari

PART II: BLOOD-BASED THERAPIES

3 Physiologic Principles and Urea Kinetic Modeling

John T. Daugirdas

4 Hemodialysis Apparatus

Suhail Ahmad, Madhukar Misra, ­Nicholas Hoenich, and John T. Daugirdas

5 Dialysis Water and Dialysate

Richard A. Ward and Todd S. Ing

6 Arteriovenous Fistulas and Grafts: The Basics

Tushar J. Vachharajani, Steven Wu, Deborah Brouwer-Maier, and Arif Asif

7 Venous Catheter Access: The Basics

Michael Allon and Arif Asif

8 Arteriovenous Vascular Access Monitoring and Complications

Alexander Yevzlin, Anil K. Agarwal, Loay Salman, and Arif Asif

9 Venous Catheter Infections and Other Complications 155 Loay Salman, Arif Asif, and ­Michael Allon

10 Acute Hemodialysis Prescription

Edward A. Ross, Allen R. Nissenson, and John T. Daugirdas

11 Chronic Hemodialysis Prescription

John T. Daugirdas

12 Complications during Hemodialysis

Richard A. Sherman, John T. Daugirdas, and Todd S. Ing

13 Dialyzer Reuse

14 Anticoagulation 252 Andrew Davenport, Kar Neng Lai, Joachim Hertel, and Ralph J. Caruana

15 Continuous Renal Replacement Therapies

Boon Wee Teo, Jennifer S. Messer, Horng Ruey Chua, Priscilla How, and Sevag Demirjian

16 Home and Intensive Hemodialysis

Gihad E. Nesrallah, Rita S. Suri, Robert M. Lindsay, and Andreas Pierratos

17 Hemodiafiltration 321 Bernard Canaud, Sudhir Bowry, and Stefano Stuard

18 Therapeutic Apheresis

Dobri D. Kiprov, Amber Sanchez, and Charles Pusey

19 The Relevance of Sorbent Technology Today

Jose A. Diaz-Buxo, Stephen A. Merchant, David Updyke, and Susan E. Bentley

20 Use of Dialysis and Hemoperfusion in the Treatment of Poisoning

James F. Winchester, Nikolas B. Harbord, Elliot Charen, and Marc Ghannoum

PART III: PERITONEAL DIALYSIS

21 Physiology of Peritoneal Dialysis

Peter G. Blake and John T. Daugirdas

22 Apparatus for Peritoneal Dialysis

Olof Heimbürger and Peter G. Blake

23 Peritoneal Dialysis Catheters, Placement, and Care

John H. Crabtree and Arsh Jain

24 Peritoneal Dialysis for the Treatment of Acute Kidney Injury

Daniela Ponce, André Luis Balbi, and Fredric O. Finkelstein

25 Adequacy of Peritoneal Dialysis and Chronic Peritoneal Dialysis Prescription

Peter G. Blake and John T. Daugirdas

26 Volume Status and Fluid Overload in Peritoneal Dialysis

Neil Boudville and Peter G. Blake

27 Peritonitis and Exit-Site Infection

Cheuk-Chun Szeto, Philip K.-T. Li, and David J. Leehey

28 Hernias, Leaks, and Encapsulating Peritoneal Sclerosis

Joanne M. Bargman

29 Metabolic, Acid-Base, and Electrolye Aspects of Peritoneal Dialysis

PART IV: CLINICAL PROBLEM AREAS

30 Psychosocial Issues

Scott D. Cohen, Daniel Cukor, and Paul L. Kimmel

Michael V. Rocco and T. Alp Ikizler

David J. Leehey, Mary Ann Emanuele, and Nicholas Emanuele

Carmine Zoccali and Francesca ­Mallamaci

34 Hematologic Abnormalities

Steven Fishbane and Hitesh H. Shah

David J. Leehey, Jacqueline T. Pham, Tran H. Tran, and Joseph R. Lentino

36 Bone Disease

Daniel W. Coyne, Derek S. Larson, and James A. Delmez

37 Dialysis in Infants and Children

Susan R. Mendley

38 Cardiovascular Disease

Daniel E. Weiner and Mark J. Sarnak

39 Obstetrics and Gynecology in Dialysis Patients

Susan Hou and Susan Grossman

40 Nervous System and Sleep Disorders

Christopher W. McIntyre

Appendix A: Tools for Estimating Glomerular Filtration Rate and Daily Creatinine Excretion

Appendix B: Nutritional Tools

Appendix C: Urea Kinetic Modeling

Appendix D: Molecular Weights and Conversion Tables

PART I CHRONIC KIDNEY DISEASE MANAGEMENT

Approach to Patients with Chronic Kidney Disease, Stages 1–4 Ajay Singh

Chronic kidney disease (CKD) can be defined in a variety of ways. The US Preventive Health Service defines it as decreased kidney function, with size-adjusted estimated glomerular filtration rate (eGFR/1.73 m2) 60 years, indigenous racial origin, and a family history of CKD. A. Urinary protein measurement. The US Preventive Health Service recommends urinary protein measurement as a screening test in all high-risk individuals. The American Diabetes Association (ADA) recommends that an evaluation for microalbuminuria be performed in all type 2 diabetic patients at the time of diagnosis and in all type 1 diabetic patients 5 years after initial evaluation. Screening can be done by urine dipstick, but a more reliable method is an early morning measurement of the ­albumin-to-creatinine ratio in a spot urine sample. The dipstick used should be able to detect both albumin and evidence of blood or white cells. If the dipstick test suggests either blood or white cell activity, then a microscopic analysis of the urinary sediment should be performed. Table 1.1 lists several limitations of urine dipstick evaluation. One problem with urine dipstick tests is that they measure concentration only, and can give falsely negative results in a dilute urine. The urine albumin-to-creatinine ratio (UACR) overcomes this problem by looking at the ratio of albumin to creatinine, as both will be affected by dilution, and the effects of dilution will 2

Chapter 1 / Approach to Patients with Chronic Kidney Disease, Stages 1–4 TABLE

Limitations of Urine Dipstick

False Negatives Low urine-specific gravity (1.030)

tend to cancel out. In terms of milligrams albumin per gram or millimole of creatinine, normoalbuminuria is defined as 30 mg/mmol). These cutoffs correspond only roughly to albuminuria measured in terms of milligrams per day (e.g., 30 and 300 mg per day), and they assume that 1 g of creatinine is being excreted per day. In fact, the average amount of creatinine excreted per day is actually higher, and as discussed elsewhere in this chapter, creatinine excretion is greater in men than in women and in young people versus older people. However, fine-tuning these “cutoff ” UACR ratios is not of great clinical importance, as the risk of increased urine albumin excretion is continuous, and risk is increased even when the albumin excretion is 28 Postoperative aortic aneurysm repair Ambulatory patient/mobility required for rehabilitation 2. Femoral Critically ill and bed-bound with body mass index 28 kg/m2), although the extent of this risk probably depends on the distribution of body fat. When femoral catheters are used, the length must be sufficient (usually at least 20 cm) so that the tip is in the inferior vena cava to permit better flow and to minimize recirculation. Another finding from the Cathedia Study was that delivered URR and Kt/V were similar with femoral and jugular catheters (Dugué, 2012). The European Best Practices

124 Part II / Blood-Based Therapies

Group does not agree with the order of preference of insertion sites listed in Table 7.1, and gives second preference to the left internal jugular vein, and recommends that femoral catheters be discouraged (Vanholder, 2010). C. Uncuffed versus cuffed catheter use. The risk of infection of uncuffed catheters increases markedly after the first week. For this reason, the KDOQI 2006 vascular access guidelines recommend use of a cuffed catheter if the anticipated need for dialysis is longer than 1 week. They also recommend that femoral catheters in bed-bound patients not be left in place longer than 5 days. These recommendations, especially with regard to femoral catheters, may be a bit too stringent given the results of the Cathedia Study (Dugué, 2012), where median time to catheter tip colonization was 14 days. Once the likelihood of the need for prolonged dialysis is established, an uncuffed internal jugular catheter can be replaced with a cuffed catheter. In cases where a prolonged need for dialysis is likely at the outset, a cuffed catheter can be inserted initially, in the right internal jugular vein position if possible. Recently some success has been claimed using cuffed tunneled femoral catheters (Hingwala, 2014). This has the advantage of locating the exit site away from overhanging skin folds, and easy removal, as long as removal is done within several weeks of insertion. Placing a cuffed femoral catheter allows time for more definitive access site placement, whether it be for peritoneal dialysis or hemodialysis. D. Anatomic variation and use of real-time ultrasound guidance. The central veins of the neck exhibit anatomic variability (Fig. 7.1), and occasionally one of them may be absent. Atypical or ectatic carotid arteries are also a problem. With the use of ultrasound guidance, the rate of successful internal jugular puncture on first attempt increases markedly and the rate of

FIGURE 7.1 Anatomic variability of internal jugular vein as viewed using ultrasound localization. (Modified from Caridi JG, et al. Sonographic guidance when using the right internal jugular vein for central vein access. Am J Roentgenol. 1998;171:1259–1263.)

Chapter 7 / Venous Catheter Access: The Basics

carotid artery punctures and hematoma is greatly reduced (Rabindranath, 2011). In the femoral approach, the femoral vein often is behind the artery, and this overlap worsens as one proceeds down from the inguinal ligament (Beaudoin, 2011). Here, too, the use of ultrasound helps reduce complications (Clark and Barsuk, 2014). E. Simulation-based training for catheter insertion. Venous catheter insertion for dialysis is a necessary skill for nephrology fellows to acquire, but many programs may not have resources to provide the required level of training. Simulation-based training has been proposed to remedy this, and provision of such intensive training has resulted in improved catheter-related outcomes (Clark and Barsuk, 2014). IV. INSERTION TECHNIQUE A. Initial site preparation. The catheter should be inserted using an

aseptic technique, with the operator wearing a sterile surgical gown and gloves in a maximum barrier protection environment. Prior to surgical scrub, it is helpful to examine the selected site using ultrasound to ensure that the patient has a suitable vein in the selected location. The insertion site and surrounding areas should be cleansed with surgical scrub and draped appropriately (include shoulder and chest wall if a cuffed tunneled catheter is to be inserted). The ultrasound probe should be covered with a sterile sheath. B. Internal jugular approach. The ultrasound probe may be placed parallel to the long axis of the vessel and the cannulation needle inserted adjacent to the end or short axis of the probe. Alternatively, the probe may be placed perpendicular to the long axis of the vessel. This approach gives the vein the more typical appearance of a circle but limits the visualization of the needle. The vein typically collapses with gentle pressure of the probe, whereas the artery does not. Additionally, the vein diameter increases with Valsalva maneuver and can be easily observed with ultrasound. For internal jugular vein cannulation as an example, the ultrasound probe is placed parallel and superior to the clavicle, over the groove between the sternal and clavicular heads of the sternocleidomastoid muscle. It is important to avoid inserting the catheter through the muscle, as this is uncomfortable for the patient and leads to catheter dysfunction as the neck is rotated. 1. Initial insertion of the guidewire through a 21G needle. The site for insertion is infiltrated with local anesthesia. Using realtime ultrasound guidance, a 21G micropuncture needle with an attached syringe is inserted into the vein. The small needle limits potential complications if the carotid artery is inadvertently punctured compared to a larger 18G needle, which is usually included in commercially available dialysis catheter trays. Under direct visualization, the vein will be seen to gently push in before penetration of the anterior vein wall. The syringe is removed, and a 0.018″

126 Part II / Blood-Based Therapies

guidewire is inserted through the needle. The guidewire is advanced. The position of the guidewire is confirmed using fluoroscopy. 2. Insertion of the dilator over the guidewire. The needle is then removed and a coaxial 5-French dilator is then advanced over the guidewire. The guidewire and 3-French inner translational dilator are removed, leaving the 5-French outer dilator in place. A flow switch or stopcock is attached to the dilator to prevent the possibility of an air embolism. 3. Uncuffed catheter insertion. The next step depends on whether one is placing a noncuffed temporary or cuffed tunneled catheter. For temporary catheter placement, a standard 0.035″ guidewire is advanced into the vein and then the 5-French dilator is removed, leaving the guidewire. In stepwise fashion, dilators of increasing size are passed over the guidewire to progressively dilate the soft tissue and venous tract; the dilator should move freely on the guidewire. The dilator should not be forcefully advanced, as it is possible for the dilator to get off axis and impinge on the guidewire and perforate the vein and/or the mediastinum. Consequently, one does not need to advance the entire length of the dilator as only the dilatation of the track from the skin to the vein is desired. If there is any doubt as to location of the dilator or if there is hesitancy or difficulty in dilating the tract, fluoroscopy should be used to assist in placement. The last dilator is then exchanged for the temporary catheter, which is advanced over the guidewire into position. After securing the catheter in place, a chest radiograph should be obtained for confirmation of correct positioning and to check for any complications, if a fluoroscope was not available during insertion. If the patient requires long-term dialysis support, the temporary noncuffed catheter, when located in the internal jugular vein, may be safely converted to a cuffed tunneled catheter if there is no evidence of an exit-site infection. 4. Cuffed catheter insertion a. Creating the skin exit site and tunnel. For cuffed tunneled

catheter insertion, a small skin incision is made from the 5-French dilator exit site extending laterally. The subcutaneous tissue is then exposed with blunt dissection, creating a subcutaneous pocket so that the catheter bend will be kink-free. Further dissection is made to ensure that the soft tissue around the 5-French dilator is free. The catheter exit site is then located. This may be accomplished by using the fourth rib interspace landmark technique, or the catheter length may be determined more precisely by using a guidewire to measure the distance from the insertion site to the midright atrium. Using this measurement as a guide, the length of tunnel may then be determined so that the cuff is within the tunnel approximately 1–2 cm from the exit site.

Chapter 7 / Venous Catheter Access: The Basics

5. Inserting the catheter through the skin exit site. Once the exit

site for the catheter is identified, the area is infiltrated with local anesthesia; a puncture is made through the skin using a number 11 knife blade inserted parallel to the skin. The knife is inserted to the widest point of the blade; this incision accommodates most dual-lumen catheters. A long needle is used to infiltrate the tunnel tract with local anesthesia extending from the exit site to the venotomy insertion site. The catheter is mounted on the end of the tunneling device, and the tunneling device is pulled from the exit site subcutaneously to the insertion site. The cuff of the catheter is pulled into the tunnel, and the tunneling device is then removed from the catheter. 6. Dilating the deep tissues and venous tract. A guidewire (Benson or angled glidewire) is now passed through the dilator into the inferior vena cava. Placement of the guidewire into the inferior vena cava decreases the likelihood of cardiac arrhythmias. The guidewire provided with most catheter trays may also be used. The 5-French dilator is then removed, and in stepwise fashion, dilators of increasing size are passed over the guidewire in order to progressively dilate the soft tissue and venous tract. The dilator should move freely on the guidewire. It is possible for the dilator to get off axis and impinge on the guidewire and perforate the vein and/or the mediastinum. In this context, one does not need to advance the entire length of the dilator as only the dilatation of the track from the skin to the vein is required. If there is any doubt as to the location of the dilator or if there is hesitancy or difficulty in dilating the tract, the fluoroscope should be used to verify proper positioning. 7. Completing catheter insertion. After the final dilation, the dilator is inserted with peel-away sheath. As one inserts the sheath, a resistance is felt as the sheath goes through the soft tissue and then a final resistance as it enters the vein. The dilator and sheath are then removed and the catheter is threaded over the guidewire without using the sheath and advanced through the venous tract into final position (sheathless catheter insertion). One may need to slightly torque the catheter in order to advance it through the tract. This maneuver decreases the possibility of air embolism and may result in both a smaller venotomy and in less postprocedure bleeding. Alternatively, if the peel-away sheath is used, the sheath is advanced slightly and the dilator removed while occluding the sheath, leaving the guidewire in place to ensure access is available if there are any difficulties. The sheath should be grasped between the finger and thumb of one’s hand in order to occlude the sheath. This prevents bleeding and/or aspiration of air while leaving enough length of the sheath to insert the catheter. Once the dilator and guidewire have been removed, the catheter is threaded

128 Part II / Blood-Based Therapies

over the wire and advanced into the opening of the sheath in such a way as to avoid twisting the catheter. The catheter is fed through the sheath. The catheter is pushed farther into the sheath, and the sheath is peeled downward toward the skin. As soon as the catheter is advanced maximally, the sheath is pulled out and then peeled down outside of the venotomy. This avoids the sheath creating a larger venous tract. 8. Setting and securing the catheter cuff. Once the sheath has been completely removed, the catheter is pulled back into the tunnel so that the cuff now is approximately 1–2 cm from the exit site. The catheter is now checked to ensure that it is functioning properly. A 10-mL syringe should be able to rapidly pull back blood without any shuttering if the catheter is to deliver a blood flow >300 mL/min. The venotomy insertion site at the neck is closed using appropriate suture after confirmation of adequate flow. Sutures should not be placed at the exit site as they serve as a nidus for infection. Additional suture is used to hold the catheter at the hub. Using “air knots” to secure the catheter hub increases patient comfort and decreases the likelihood of skin necrosis. The subcutaneous cuff will ultimately hold the catheter in position and anchor it to the subcutaneous tissue. Topical antibiotic ointment may be applied to the incisions and needle puncture sites, and a gauze dressing is applied. C. Femoral approach. Uncuffed catheters normally are used, but as noted earlier, cuffed catheters also may be inserted. The patient is placed flat on the back with the knee slightly flexed and leg abducted and rotated outward. The groin is shaved, cleansed, painted with antiseptic, and draped. The femoral vein should be located 2–4 cm below the inguinal ligament using a 21G needle filled with heparinized saline or with local anesthetic. As noted earlier, real-time ultrasound guidance improves the chance of a successful procedure. A small amount of local anesthetic can be infiltrated around the vein to prevent venous spasm. Once the vein is located, the smallgauge needle is withdrawn and replaced with an 18G needle. A guidewire is inserted through the needle into the vein. It is important for the guidewire to be freely movable back and forth after it is fully inserted. If the guidewire feels tight, chances are that it has entered a side branch of the iliofemoral vein. Under these circumstances catheter insertion should not be attempted; rather, the guidewire should be withdrawn completely, the angle of the needle in the vein changed (sometimes the needle hub has to be lowered to the skin level to be almost parallel to the vein), and the guidewire reinserted. After free to-and-fro movement of the inserted guidewire is achieved, the 18G needle is removed and the cannula reinserted. The remainder of the procedure then generally follows the description for jugular vein insertion, above.

Chapter 7 / Venous Catheter Access: The Basics

V. INSERTION-RELATED COMPLICATIONS. These are listed in Table 7.2.

Arterial puncture by the initial small-gauge probing needle should be treated by uninterrupted local pressure for 15–20 minutes. The cannula should never be inserted into an artery. In case of inadvertent arterial insertion of a dialysis catheter, dialysis should be postponed and surgical opinion sought to avoid a major hematoma and tracheal compression. In the case of femoral insertions, retroperitoneal bleeding may be severe and life-threatening with either puncture of the artery or inadvertent puncture of the back wall of the vein. A large pneumothorax or hemothorax usually requires drainage using a surgically implanted chest tube. Perforation of the superior vena cava or cardiac chambers can be life-­threatening. Diagnosis is suggested by unexplained chest pain, shortness of breath or hypotension soon after commencing dialysis. Surgical intervention is sometimes needed for correction. Infection-related complications can be minimized at time of catheter insertion by assuring adequate hand hygiene, use of sterile gown, mask, gloves and caps for the operator, and a large ( full body) sterile drape to cover the patient, and application of chlorhexidine skin antisepsis prior to the procedure (O’Grady, 2011).

VI. CARE AND USE OF VENOUS CATHETERS A. Dressings. During catheter connect and disconnect proce-

dures, both dialysis staff and patient should wear surgical masks. A face shield should not be used without a surgical mask because the shield tends to focus the wearer’s breath directly on the exposed catheter hub. The lumen and catheter tips should never remain open to air. A cap or syringe should

Complications of Central Venous Catheterization

Immediate Complications Arterial puncture (all) Pneumothorax (IJ, SC) Hemothorax (IJ, SC) Arrhythmias (IJ, SC) Air embolism (all IJ, SC .. F) Perforation of cardiac chamber (IJ, SC) Pericardial tamponade (IJ, SC) Retroperitoneal hemorrhage (F) Delayed Complications Thrombosis (all) Infection (all) Central venous stenosis (SC .. IJ) Arteriovenous fistula (all) Injury to Adjacent Structures Brachial plexus (IJ, SC) Recurrent laryngeal nerve (IJ, SC) IJ, internal jugular; SC, subclavian; F, femoral.

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always be placed on or in the catheter lumen while maintaining a clean field under the catheter connectors. Catheter lumens must be kept sterile: Interdialytic infusions through the catheter are forbidden. After each dialysis, catheter hubs or blood line connectors should be soaked in antiseptic for 3–5 minutes, and then dried prior to separation. Chlorhexidine-based antiseptic solutions (>0.5%) appear to give better results than povidone-iodine (Mimoz, 2007; Onder, 2009). After disconnecting each line from the catheter, the threads of the catheter connector should be scrubbed with chlorhexidine (Table 7.3). The catheter should be covered with a sterile dry dressing. Nonbreathable or nonporous transparent film dressings should be avoided as they pose a greater threat of exit-site colonization than dry dressings. The best type of dressing to use is still a matter of controversy. The CDC recommendations are to “use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site” (O’Grady, 2011). The CDC has available resources including videos to show best practice techniques of making such catheter dressing changes (CDC, 2014).

B. Risk of air embolism on removal of dialysis catheters from the neck. After removal of a jugular venous catheter, lethal air

embolism has been reported (Boer and Hené, 1999). Because of this nonnegligible risk, specific protocols should be in place for removal of venous catheters from the neck. The protocol recommended by Boer and Hené (1999) is as follows: 1. No heparin on day of planned removal. Protamine given if heparin is already on board 2. Patient in head down position during catheter removal. Patient instructed not to cough or inhale deeply during removal 3. Air-occlusive dressing with generous amount of an inert ointment to provide an instantaneous air seal 4. Patient observed for 30 minutes before leaving dialysis facility 5. Air-occlusive dressing left in place for at least 24 hours C. Catheter exchange over a guidewire (technique). The reasons for catheter exchange over a guidewire (dysfunction, infection) are discussed in detail in Chapter 9. The technique for exchange of a catheter in the internal jugular vein is as follows: The chest wall and the old catheter are prepped and draped in a sterile fashion. The operators should wear two sterile gloves. Local anesthesia is infiltrated at the old exit site and around the cuff of the existing catheter. Both catheter ports are aspirated to get rid of the heparin. Using a hemostat, blunt dissection is performed to free up the catheter cuff. At this point, a guidewire is introduced into the venous lumen of the catheter and navigated into the inferior vena cava. The catheter is gently pulled back so that it is situated at the brachiocephalic vein. A contrast injection is performed through the atrial port

Chapter 7 / Venous Catheter Access: The Basics TABLE

The Centers for Disease Control Core Interventions for Dialysis Bloodstream Infection (BSI) Prevention

1. Surveillance and feedback using NHSN Conduct monthly surveillance for BSIs and other dialysis events using CDC’s National Healthcare Safety Network (NHSN). Calculate facility rates and compare with rates in other NHSN facilities. Actively share results with front-line clinical staff 2. Hand hygiene observations Perform observations of hand hygiene opportunities monthly and share results with clinical staff 3. Catheter/vascular access care observations Perform observations of vascular access care and catheter accessing quarterly. Assess staff adherence to aseptic technique when connecting and disconnecting catheters and during dressing changes. Share results with clinical staff 4. Staff education and competency Train staff on infection control topics, including access care and aseptic technique. Perform competency evaluation for skills such as catheter care and accessing every 6–12 months and upon hire 5. Patient education/engagement Provide standardized education to all patients on infection prevention topics including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit 6. Catheter reduction Incorporate efforts (e.g., through patient education, vascular access coordinator) to reduce catheters by identifying and addressing barriers to permanent vascular access placement and catheter removal 7. Chlorhexidine for skin antisepsis Use an alcohol-based chlorhexidine (>0.5%) solution as the first-line skin antiseptic agent for central line insertion and during dressing changesa 8. Catheter hub disinfection Scrub catheter hubs with an appropriate antiseptic after cap is removed and before accessing. Perform every time catheter is accessed or disconnectedb 9. Antimicrobial ointment Apply antibiotic ointment or povidone-iodine ointment to catheter exit sites during dressing changec a Povidone-iodine (preferably with alcohol) or 70% alcohol by itself is alternative for patients with chlorhexidine intolerance. b If closed needleless connector device is used, disinfect connector device as per manufacturer’s instructions. c CDC recommends using povidone-iodine ointment or bacitracin/gramicidin/polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at each hemodialysis session. Bacitracin/gramicidin/polymyxin B ointment is not currently available in the United States. Triple antibiotic ointment (bacitracin/neomycin/polymyxin B) is available and might have a similar benefit but studies have not thoroughly evaluated its effect for prevention of bloodstream and exit-site infections. Other ointments that have been studied include single antibiotic ointments (e.g., m ­ upirocin). However, concerns exist about development of antimicrobial resistance and also their ability to cover the spectrum of potential pathogens (e.g., gram-negative and gram-positive bacteria) that can cause bloodstream infections in dialysis patients. Another important consideration is that ingredients in antibiotic and povidone-iodine ointments may interact with the chemical composition of certain catheters. Therefore, before any product is applied to the catheter, first check with the catheter manufacturer to ensure that the selected ointment will not interact with the catheter material. Reprinted from National Center for Emerging and Zoonotic Infectious Diseases, Center for Disease Control and Prevention. http://www.cdc.gov/dialysis/PDFs/Dialysis-Core-Interventions-5_10_13.pdf.

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of the catheter to ascertain the presence of fibroepithelial sheath. If present, percutaneous balloon angioplasty should be considered and contrast injection repeated to evaluate the results of the sheath treatment. The old catheter should be removed while the wire is kept in place. At this point, the operator(s) should remove the outer pair of gloves before handling the new catheter. This maneuver helps minimize the transfer of infectious organisms from the old catheter to the new catheter. The new catheter is then advanced over the wire and into the right atrium. The catheter function is assessed as described earlier. D. Bathing and showering. The exit site should never be immersed in bath water. Showering is best avoided, but if the patient showers it should be done prior to coming to the dialysis unit, where a new dressing and antibacterial ointment will be promptly applied. Showering should be done only after the exit-site sinus tract has become established. A recent quality assurance study suggested that in selected patients, showering in combination with a no-dressing technique for tunneled central venous catheters did not increase infection risk ­(Lawrence, 2014). Immersive swimming, as in a chlorinated pool, is generally discouraged for fear of infection. E. Catheter locks 1. Heparin. After each dialysis session, the dead space of each

lumen is filled with heparin through the catheter injection ports using 1,000–5,000 units/mL. Any lock solution will leak out to the level of the most proximal side hole of the catheter. Thus, use of higher heparin concentration (5,000 vs. 1,000 units/mL) may result in significant systemic anticoagulation, but in one study, the higher heparin concentration was associated with lower need for tissue plaminogen activator use (Maya, 2010). The dead space of each catheter lumen varies among manufacturers and length of catheter. The required volume of heparin is usually labeled on the catheter hub. It is important to record this information on the patient’s chart so it is readily available to the dialysis staff. Injection of a volume of heparin solution larger than necessary should be avoided as it results in some degree of systemic anticoagulation that may be hazardous to patients at risk for bleeding. Prior to each dialysis, the heparin in each lumen is aspirated, the catheter flushed with heparinized saline (100 units/mL), and hemodialysis initiated. 2. Citrate 4%. Citrate can be used as an anticoagulant because it chelates calcium, which is essential for clotting to occur. A meta-analysis performed in 2014 concluded that citratebased lock solutions containing antibiotics or antiseptics were better than their heparin-containing counterparts in reducing the rate of central line–associated bloodstream infection (CLABSI). Citrate alone was more effective than heparin, but primarily when a high concentration (30%) was

Chapter 7 / Venous Catheter Access: The Basics

used. At lower concentrations of citrate there seemed to be no advantage over heparin (Zhao, 2014). Citrate has been shown to leak out of catheter locks into the circulation fairly rapidly, quickly lowering its concentration to levels below those known to inhibit bacterial growth (Schilcher, 2014). In the United States, in the year 2000, use of very high concentrations of citrate in a dialysis catheter was associated with cardiac arrhythmia and patient death, presumably due to inadvertent injection of concentrated citrate into the left atrium, acutely lowering the ionized calcium level (­Polaschegg and Sodemann, 2003). It is prudent to use the lowest concentration (4% citrate), recognizing that efficacy of citrate at this concentration alone may be no better than that of heparin. Citrate use at any concentration is problematic in countries (such as the United States) where it is not conveniently available in small volumes to be used for a locking solution. 3. Other locks. Other lock solutions have contained heparin, citrate, ethanol, or EDTA plus one or more antibiotics or antiseptics. For the moment, use of antibiotic-containing locks has not yet become mainstream, due in various proportions to added cost, practical issues relating to compounding, and fear of promoting growth of resistant organisms. A locking solution containing vancomycin and gentamicin was found to increase the prevalence of Staphylococcus and antibioticresistant Enterobacter, for example (Dixon, 2012). For the moment, neither the CDC nor the US National Kidney Foundation recommend the routine use of lock solutions containing antibiotics (Camins, 2013), while the European Best Practices Group is somewhat equivocal (Vanholder, 2010). Lock solution for prevention of infections in catheters is an active area of research. One goal is not only to sterilize the inside of the catheter but also to prevent the formation of biofilm. Locking solutions containing ethanol, citrate, or EDTA have a theoretical advantage of having some activity in affecting biofilm development. A solution containing glyceryl trinitrate, citrate, and ethanol has been reported to have some effects against not only common bacteria found in catheters but also biofilm (Rosenblatt, 2013). Other locking solutions have been developed and are in various stages of testing. A mixture of citrate, methylene blue, methylparaben, and propylparaben (C-MB-P) was reported to reduce the rate of CLABSIs by a substantial amount (Maki, 2011). There is some enthusiasm about locks containing a combination of taurolidine and citrate. It is possible that the use of taurolidine, which tends to function as a disinfectant and which inhibits the formation of biofilm, may not be associated with emergence of resistant bacteria (Liu, 2014). F. Prophylactic antibiotics. Systemic antibiotics are not given routinely prior to cuffed catheter insertion. 1. Exit-site ointment. Mupirocin ointment treatment of the catheter exit site to lower Staphylococcus colonization has

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been shown to reduce the catheter infection rate and to increase the catheter survival rate (McCann and Moore, 2010; O’Grady, 2011), but is not widely used for fear of longterm emergence of mupirocin-resistant organisms. The CDC recommends using exit-site ointments (Table 7.3) but is very concerned about the emergence of resistant organisms. The European Renal Best Practices group, in a 2010 commentary, recommends use of exit-site antibiotic ointment only until the insertion site has healed ­(Vanholder, 2010). As an intermediate strategy, use of exit-site ointments can be limited to those patients who evidence repeated episodes of infection. Prior to use of any ointment, one should check to make sure that the vehicle used to dissolve the ointment does not adversely react with the plastics in the catheter material. 2. Nasal decolonization. In patients harboring Staphylococcus in the nose, nasal decolonization has been shown to reduce the rate of CLABSI (Abad, 2013), but the specter of mupirocin resistance remains (Teo, 2011). This remains a more attractive treatment option in selected patients than for the unit as a whole, but nasal decolonization (of multidrugresistant S. aureus, for example) has been applied to entire dialysis units with encouraging short-term results (Kang, 2012). References and Suggested Readings Abad CL, et al. Does the nose know? An update on MRSE decolonization strategies. Curr Infect Dis Rep. 2013;15:455–464. Allon M. Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis. 2004;44:779–791. Beathard GA. Management of bacteremia associated with tunneled-cuffed hemodialysis catheters. J Am Soc Nephrol. 1999;10:1045–1049. Beaudoin FL, et al. Bedside ultrasonography detects significant femoral vessel overlap: implications for central venous cannulation. Can J Emerg Med. 2011;13:245–250. Bevilacqua JL, et al. Comparison of trisodium citrate and heparin as catheter-locking solution in hemodialysis patients. J Bras Nefrol. 2011;33:68–73. Boer WH, Hené RJ. Lethal air embolism following removal of a double lumen jugular catheter. Nephrol Dial Transplant. 1999;14:1850–1852. Camins BC. Preventions and treatment of hemodialysis-related bloodstream infections. Semin Dial. 2013;26:476–481. Centers for Disease Control. Guidelines of the prevention of intravascular ­catheter-related infections. 2011. http://www.cdc.gov/hicpac/pdf/guidelines/ bsi-guidelines-2011.pdf. Centers for Disease Control. Training video and print resources for preventing bloodstream and other infections in outpatient hemodialysis patients. Best practices for dialysis staff. 2014. http://www.cdc.gov/dialysis/prevention-tools/training-video​ .html. Clark EG, Barsuk JH. Temporary hemodialysis catheters: recent advances. Kidney Int. 2014. doi:10.1038/ki.2014.162. Clase CM, et al. Thrombolysis for restoration of patency to hemodialysis central venous catheters: a systematic review. J Thromb Thrombolysis. 2001;11(2):127–136. Dixon JJ, Steele M, Makanjuola AD. Anti-microbial locks increase the prevalence of Staphylococcus aureus and antibiotic-resistant Enterobacter: observational retrospective cohort study. Nephrol Dial Transplant. 2012;27:3575–3581. Drew DA, Lok CE. Strategies for planning the optimal dialysis access for an individual patient. Curr Opin Nephrol Hypertens. 2014;23:314–320.

Chapter 7 / Venous Catheter Access: The Basics

Dugué AE, et al; for the Cathedia Study Group. Vascular access sites for acute renal replacement in intensive care units. Clin J Am Soc Nephrol. 2012;7:70–77. Frankel A. Temporary access and central venous catheters. Eur J Vasc Endovasc Surg. 2006;31:417–422. Haymond J, et al. Efficacy of low-dose alteplase for treatment of hemodialysis catheter occlusions. J Vasc Access. 2005;6:76–82. Hebert C, Robicsek A. Decolonization therapy in infection control. Curr Opin Infect Dis. 2010;23:340–345. Hingwala J, Bhola C, Lok CE. Using tunneled femoral vein catheters for “urgent start” dialysis patients: a preliminary report. J Vasc Access. 2014;15(suppl 7):101–108. Johnson DW, et al. A randomized controlled trial of topical exit site mupirocin application in patients with tunnelled, cuffed haemodialysis catheters. Nephrol Dial Transplant. 2002;17:1802–1807. Kang YC, et al. Methicillin-resistant Staphylococcus aureus nasal carriage among patients receiving hemodialysis in Taiwan: prevalence rate, molecular characterization and de-colonization. BMC Infect Dis. 2012;12:284. Lawrence JA, et al. Shower and no-dressing technique for tunneled central venous hemodialysis catheters: a quality improvement initiative. Nephrol Nurs J. 2014;​ 41:67–72. Lee T, Barker J, Allon M. Tunneled catheters in hemodialysis patients: reasons and subsequent outcomes. Am J Kidney Dis. 2005;46:501–508. Little MA, Walshe JJ. A longitudinal study of the repeated use of alteplase as therapy for tunneled hemodialysis dysfunction. Am J Kidney Dis. 2002;39:86–91. Liu H, et al. Preventing catheter-related bacteremia with taurolidine-citrate catheter locks. A systemic review and meta-analysis. Blood Purif. 2014;37:179–187. Lok CE, et al. A patient-focused approach to thrombolytic use in the management of catheter malfunction. Semin Dial. 2006;19:381–390. Maki DG, et al. A novel antimicrobial and antithrombotic lock solution for hemodialysis catheters: A multi-center, controlled, randomized trial. Crit Care Med. 2011;39:613–620. Maya ID, Allon M. Outcomes of tunneled femoral hemodialysis catheters: comparison with internal jugular vein catheters. Kidney Int. 2005;68:2886–2889. Maya ID, et al. Does the heparin lock concentration affect hemodialysis catheter patency? Clin J Am Soc Nephrol. 2010;5:1458–1462. McCann M, Moore ZE. Interventions for preventing infectious complications in haemodialysis patients with central venous catheters. Cochrane Database Syst Rev. 2010;(1):CD006894. Mermel LA, et al. Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis. 2001;32:1249–1272. Mimoz O, et al. Chlorhexidine-based antiseptic solution vs alcohol-based ­povidone-iodine for central venous catheter care. Arch Intern Med. 2007;167:​ 2066–2067. Mokrzycki MH, et al. A randomized trial of minidose warfarin for the prevention of late malfunction in tunneled, cuffed hemodialysis catheters. Kidney Int. 2001;​ 59:1935–1942. Murea M, et al. Risk of catheter-related bloodstream infection in elderly patients on hemodialysis. Clin J Am Soc Nephrol. 2014;9:764–770. O’Grady NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011;39(suppl):S1–S34. Oliver MJ, et al. Risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: a prospective study. Kidney Int. 2000;58:2543–2545. Onder AM, et al. Chlorhexidine-based antiseptic solutions effectively reduce catheterrelated bacteremia. Pediatr Nephrol. 2009;224:1741–1747. Patel PR, et al. Bloodstream infection rates in outpatient hemodialysis facilities ­participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis. 62:322–30, 2013. Polaschegg HD, Sodemann K. Risks related to catheter locking solutions containing concentrated citrate. Nephrol Dial Transplant. 2003;18:2688–2690. Rabindranath KS, et al. Ultrasound use for the placement of haemodialysis catheters. Cochrane Database Syst Rev. 2011;(11):CD005279. Rosenblatt J, et al. Glyceryl trinitrate complements citrate and ethanol in a novel antimicrobial catheter lock solution to eradicate biofilm organisms. Antimicrob Agents Chemother. 2013;57:3555–3560.

136 Part II / Blood-Based Therapies Schilcher G, et al. Loss of antimicrobial effect of trisodium citrate due to ‘lock’ spillage from haemodialysis catheters. Nephrol Dial Transplant. 2014;29:914–919. Silva TNV, et al. Approach to prophylactic measures for central venous catheterrelated infections in hemodialysis. A critical review. Hemodial Int. 2014;18:15–23. Teo BW, et al. High prevalence of mupirocin-resistant staphylococci in a dialysis unit where mupirocin and chlorhexidine are routinely used for prevention of catheterrelated infections. J Med Microbiol. 2011;60(pt 6):865–867. Vanholder RM, et al. Diagnosis, prevention, and treatment of haemodialysis catheterrelated bloodstreams infections (CRBSI): a position statement of European Renal Best Practice (ERBP). Nephrol Dial Transplant. 2010;3:234–246. Zhao Y, et al. Citrate versus heparin lock for hemodialysis catheters: a systematic review and meta-analysis of randomized controlled trials. Am J Kidney Dis. 2014;63:479–490.

Web References American Society of Diagnostic and Interventional Nephrology. http://www.asdin​ .org/. CDC guidelines for prevention of intravascular catheter-related infections. http:// www.cdc.gov/dialysis. HDCN vascular access channel. http://www.hdcn.com/ch/access/. KDOQI 2006 access guidelines. http://www.kidney.org/professionals/kdoqi/­guideline_ upHD_PD_VA/index.htm. Vascular Access Society guidelines. http://www.vascularaccesssociety.com/guidelines​ .html. YouTube link (11 min). https://www.youtube.com/watch?v=_0zhY0JMGCA&feature​ =youtu.be.

Arteriovenous Vascular Access Monitoring and Complications Alexander Yevzlin, Anil K. Agarwal, Loay Salman, and Arif Asif

Once the AV access has been in use, the most important factors that limit its survival are stenosis, thrombosis, and infection. In general, complications occur more commonly in grafts than in AV fistulas. I. STENOSIS. Vascular access stenosis is a harbinger of thrombo-

sis, reduces access blood flow, and can lead to underdialysis. The most common cause of stenosis in AV grafts is neointimal ­hyperplasia, which usually occurs at or just distal to the graft– vein anastomosis. In AV fistulas, the location and cause of stenosis is more varied, with the juxta-anastomotic region being a frequent site. Common sites of stenosis in AV fistulas and grafts are shown in Figures 8.1 and 8.2. Because access patency is much worse after thrombectomy than after elective angioplasty, current KDOQI guidelines recommend prospective monitoring and surveillance of AV fistulas and grafts for hemodynamically significant stenosis. Not all guidelines recommend routine monitoring, however, and there is controversy regarding the overall clinical benefit of maintaining an access surveillance program (Kumbar, 2012; Paulson, 2012). Randomized controlled trials have not consistently shown that surveillance improves outcomes in grafts; in fistulas, surveillance has been shown to reduce the rate of thrombosis, but may not prolong overall fistula life. There are several strategies to detect stenosis prior to definitive visualization of the access tract by Doppler ultrasound and, in the case of central vein stenosis, by venography. These early detection strategies depend on indirectly observing access pressure, flow, or recirculation during dialysis. The optimum early detection strategy differs somewhat for fistulas versus grafts, and for forearm versus upper arm locations. The basic principles are these: (a) Recirculation of dialyzed blood across the access device immediately back through the dialysis circuit does not appear until access flow decreases to a level near to or less than flow in the extracorporeal circuit. Thus, barring inadvertent needle reversal or improper needle placement, access recirculation will not be present until access flow falls to the range of 350–500 mL/min. At this range of flow, AV grafts are already at high risk for thrombosis, 137

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