Strategies to Prevent Hemodialysis Catheter Dysfunction

Millions of patients with kidney failure rely on hemodialysis (HD) central venous catheters (CVC) for their life-sustaining dialysis treatments. CVC dysfunction necessitates removal of up to 20% of CVCs and is an important problem for patients with kidney failure. Thrombosis and fibrin sheath formation are the most common mechanisms of CVC dysfunction beyond the first week after insertion. Factors such as female sex, left-sided CVC placement and prior CVC dysfunction increase the risk of dysfunction. Patient specific factors contribute substantially to variation in the number of CVC dysfunction events. Weekly thrombolytic locks have been shown to improve CVC blood flow rates, prevent infection and reduce dysfunction requiring removal. However, routine administration may not be cost-effective in HD units with low infection rates, and targeted use among patients with established CVC dysfunction has not been studied. Concentrated heparin lock (e.g., 5000 vs. 1000 IU/ml) have been associated with lower requirements for therapeutic CVC thrombolysis but increased systemic bleeding risks and costs. Citrate 4% was non-inferior to standard heparin locks to prevent thrombosis, may cause less bleeding, and is less costly in some countries. Tunneled CVCs with a symmetrical tip have been associated with a lower risk of CVC dysfunction compared to those with a step tip. Multifaceted CVC care interventions can reduce the incidence of dysfunctional CVCs by 33% compared to usual care. Future research to identify patients at high risk of CVC dysfunction will inform individualized vascular access plans, targeted use of preventive strategies, and enrolment criteria for future clinical trials.