Authors (including presenting author) :
Chung PW(1), Wong KH(1), Or PC(1), Tsim KN(1), Liu MS(1), Chan KM(1), Ko KY(1), Chan SC(1), Chan CH(1), Tang SK(1), Tong PC(1), Wong SW(1), Ho TW(1), Chan YHE(1), Lai WM(1), Ma LT(1)
Affiliation :
Paediatric Nephrology Centre, Department of Paediatrics, Hong Kong Children’s Hospital, Kowloon Bay, Hong Kong SAR
Introduction :
Native arteriovenous fistula (AVF) is the recommended vascular access for haemodialysis (HD). Because of difficult to create AVF in paediatric patients, haemodialysis central venous catheters (HCVC) are the commonest vascular access for them. HCVC are their ‘lifeline’. The preservation of the lifeline is important to increase their dialysis adequacy and improve their survival. HCVC lumens are locked by anticoagulant solution to prevent catheter thrombosis. Alteplase is a tissue plasminogen activator, which shown to be effective for clearance of thrombosed catheters and maintaining line patency. There is increasing use of alteplase, as a catheter-locking solution in haemodialysis centre worldwide and the “alteplase lock” was initiated to use weekly in our centre since 2017. Despite instilling “alteplase lock” into the HCVC lumens weekly, we observed extensive intraluminal thrombosis and fibrin sheath, which caused inability to achieve the optimal blood flow rate, led to early termination of the dialysis, resulted in poor clearance and inadequate dialysis, with consequent adverse effect to patients’ clinical outcomes and increased the cost of patient care. In order to reduce the catheters thrombosis rates and the thrombosis-related complications, we increased our “alteplase lock” to HCVC lumens from weekly to every dialysis session (3-5 times per week).
Objectives :
1. To reduce the thrombosis-related complications in HCVC 2. To maintain the HCVC patency 3. To prolong the HCVC survival time 4. To reduce the hospital costs for the management of thrombosed HCVC
Methodology :
It was a prospective cohort study. Inclusion criteria included the patients with permanent tunneled HCVC on regular HD sessions (3-5 times per week), who were involved in both before and after the practice change. Exclusion criteria included the patients with a temporary non-tunneled HCVC, the patients with a permanent tunneled HCVC but not on regular HD sessions. The previous practice of “alteplase lock”, which was instilled to the exact volume of the HCVC lumens weekly, with “heparin lock” for the remaining post dialysis sessions. New practice was introduced by instilling “alteplase lock” after every dialysis and the use of “heparin lock” was discontinued. Data was reviewed six months before and after the practice changed. The incidence(s) of thrombosis-related complications and the surgical interventions of the HCVC were compared.
Result & Outcome :
Ninety percentage of the total HD patients (10 patients) in the centre were recruited. Results showed the numbers of thrombosis-related HCVC decreased 33.3%. The numbers of inability to attain adequate blood flow rate during the haemodialysis or early terminate the treatment decreased 58%. The numbers of thrombosed HCVC requiring surgical intervention decreased 33.3%. The formation of fibrin sheath required stripping decreased 80%. No clot was reported in HCVC after change of practice. In conclusion, increased the frequency of “alteplase lock” has shown to be effective for preventing HCVC thrombosis, increasing the catheters survival, reducing the surgical interventions and the treatment-related costs.
