Advertisement

Infection

, Volume 45, Issue 2, pp 139–145 | Cite as

Comparative effectiveness of 30 % trisodium citrate and heparin lock solution in preventing infection and dysfunction of hemodialysis catheters: a randomized controlled trial (CITRIM trial)

  • Franklin Correa Barcellos
  • Bruno Pereira Nunes
  • Luciana Jorge Valle
  • Thiago Lopes
  • Bianca Orlando
  • Cintia Scherer
  • Marcia Nunes
  • Gabriela Araújo Duarte
  • Maristela Böhlke
Original Paper

Abstract

Background

Central venous catheters (CVC) are the only option when hemodialysis is needed for patients without definitive vascular access. However, CVC is associated with complications, such as infection, thrombosis, and dysfunction, leading to higher mortality and expenditures. The aim of this study was to compare the effectiveness of 30 % trisodium citrate (TSC30 %) with heparin as CVC lock solutions in preventing catheter-related bloodstream infections (CRBSI) and dysfunction in hemodialysis patients.

Methods

Randomized, double-blind controlled trial comparing the event-free survival of non-tunneled CVC locked with heparin or TSC30 % in adult hemodialysis patients.

Results

The study included 464 catheters, 233 in heparin group, and 231 in TSC30 % group. The CRBSI-free survival of TSC30 % group was significantly shorter than that of heparin group. When stratified by insertion site, heparin was better than TSC30 % only in subclavian CVC. The dysfunction-free survival was not different between groups in the main analysis, but there is also a shorter survival among subclavian CVC locked with TSC30 % in stratified analysis.

Conclusion

There was no difference on CRBSI-free or dysfunction-free survival between jugular vein CVC locked with heparin or 30 % citrate. However, subclavian CVC locked with 30 % citrate presented shorter event-free survival. This difference may be related to anatomical and positional effects, CVC design, and hydraulic aspects of the lock solution.

ClinicalTrials.gov identifier

NCT02563041.

Keywords

Catheter-related bloodstream infection Hemodialysis Lock solutions Citrate 

Notes

Compliance with ethical standards

Conflict of interest

The authors of this study have no conflict of interest. The results presented in this paper have not been published previously in whole or part, expect in abstract form. There is no funding source.

References

  1. 1.
    Mills KT, Xu Y, Zhang W, Bundy JD, Chen SC, Kelly TN, Chen J, He1 J. A systematic analysis of worldwide population-based data on the global burden of chronic kidney disease in 2010. Kidney Int Adv Online Publ, Kidney Int. 2015 Jul 29. doi: 10.1038/ki.2015.230. (Epub ahead of print)
  2. 2.
    Zoccali C, Kramer A, Jager KJ. Epidemiology of CKD in Europe: an uncertain scenario. Nephrol Dial Transplant. 2010;25:1731–3.CrossRefPubMedGoogle Scholar
  3. 3.
    Pisoni RL, Arrington CJ, Albert JM, Ethier J, Kimata N, Krishnan M, Rayner HC, Saito A, Sands JJ, Saran R, Gillespie B, Wolfe RA, Port FK. Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis. Am J Kidney Dis. 2009;53:475–91.CrossRefPubMedGoogle Scholar
  4. 4.
    Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in US hemodialysis patients. Kidney Int. 2001;60:1443–51.CrossRefPubMedGoogle Scholar
  5. 5.
    Pisoni RL, Zepel L, Port FK, Robinson BM. Trends in US vascular access use, patient preferences, and related practices: an update from the US DOPPS practice monitor with international comparisons. Am J Kidney Dis. 2015;65:905–15.CrossRefPubMedGoogle Scholar
  6. 6.
    US Renal Data System. Annual data report: An overview of the epidemiology of kidney disease in the United States. Bethesda: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2014.Google Scholar
  7. 7.
    de Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302:1782–9.CrossRefPubMedGoogle Scholar
  8. 8.
    James MT, Conley J, Tonelli M, Manns BJ, MacRae J, Hemmelgarn BR, Alberta Kidney Disease Network. Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter-related infections. Ann Intern Med. 2008;148:596–605.CrossRefPubMedGoogle Scholar
  9. 9.
    Yahav D, Rozen-Zvi B, Gafter-Gvili A, Leibovici L, Gafter U, Paul M. Antimicrobial lock solutions for the prevention of infections associated with intravascular catheters in patients undergoing hemodialysis: systematic review and meta-analysis of randomized, controlled trials. Clin Infect Dis. 2008;47:83–93.CrossRefPubMedGoogle Scholar
  10. 10.
    Jaffer Y, Selby NM, Taal MW, Fluck RJ, McIntyre CW. A metaanalysis of hemodialysis catheter locking solutions in the prevention of catheter-related infection. Am J Kidney Dis. 2008;51:233–41.CrossRefPubMedGoogle Scholar
  11. 11.
    Labriola L, Crott R, Jadoul M. Preventing haemodialysis catheter- related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dial Transplant. 2008;23:1666–72.CrossRefPubMedGoogle Scholar
  12. 12.
    Zhao Y, Li Z, Zhang L, Yang J, Yang Y, Tang Y, Fu P. Citrate versus heparin lock for hemodialysis catheters: a systematic review and meta-analysis of randomized controlled trials. Am J Kidney Dis. 2014;63:479–90.CrossRefPubMedGoogle Scholar
  13. 13.
    Betjes MGH. Prevention of catheter-related bloodstream infection in patients on hemodialysis. Nat Rev Nephrol. 2011;7:257–65.CrossRefPubMedGoogle Scholar
  14. 14.
    O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002;51:1–29.PubMedGoogle Scholar
  15. 15.
    Moran J, Sun S, Khababa I, Pedan A, Doss S, Schiller B. A Randomized trial comparing gentamicin/citrate and heparin locks for central venous catheters in maintenance hemodialysis patients. Am J Kidney Dis. 2011;59:102–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Winnett G, Nolan J, Miller M, Ashman N. Trisodium citrate 46.7 % selectively and safely reduces staphylococcal catheter-related bacteraemia. Nephrol Dial Transplant. 2008;23:3592–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Allon M. Prophylaxis against dialysis catheter-related bacteremia with a novel antimicrobial lock solution. Clin Infect Dis. 2003;36:1539–44.CrossRefPubMedGoogle Scholar
  18. 18.
    Weijmer MC, van den Dorpel MA, van de Ven PJG, et al. Randomized, clinical trial comparison of trisodium citrate 30 % and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol. 2005;16:2769–77.CrossRefPubMedGoogle Scholar
  19. 19.
    Betjes MG, van Agteren M. Prevention of dialysis catheter-related sepsis with a citrate-taurolidine-containing lock solution. Nephrol Dial Transplant. 2004;19:1546–51.CrossRefPubMedGoogle Scholar
  20. 20.
    Lok CE, Appleton D, Bhola C, Khoo B, Richardson RM. Trisodium citrate 4 %––an alternative to heparin capping of haemodialysis catheters. Nephrol Dial Transplant. 2007;22:477–83.CrossRefPubMedGoogle Scholar
  21. 21.
    Grudzinski L, Quinan P, Kwok S, Pierratos A. Sodium citrate 4 % locking solution for central venous dialysis catheters––an effective, more cost-efficient alternative to heparin. Nephrol Dial Transplant. 2007;22:471–6.CrossRefPubMedGoogle Scholar
  22. 22.
    MacRae JM, Dojcinovic I, Djurdjev O, et al. Citrate 4 % versus heparin and the reduction of thrombosis study (CHARTS). Clin J Am Soc Nephrol. 2008;3:369–74.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Polaschegg HD. Catheter locking-solution spillage: theory and experimental verification. Blood Purif. 2008;26:255–60.CrossRefPubMedGoogle Scholar
  24. 24.
    Doorenbos CJ, Van den Elsen-Hutten M, Heuven MJ, et al. Estimation of trisodium citrate (Citra-Lock) remaining in central venous catheters after the interdialytic interval. Nephrol Dial Transplant. 2006;21:543–5.CrossRefPubMedGoogle Scholar
  25. 25.
    Schilcher G, Schneditz D, Ribitsch W, Horina JH, Hoenigl M, Valentin T, Rosenkranz AR, Krause R. Loss of antimicrobial effect of trisodium citrate due to ‘lock’ spillage from haemodialysis catheters. Nephrol Dial Transplant. 2014;29:914–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Power A, Duncan N, Singh SK, et al. Sodium citrate versus heparin catheter locks for cuffed central venous catheters: a single center randomized controlled trial. Am J Kidney Dis. 2009;53:1034–41.CrossRefPubMedGoogle Scholar
  27. 27.
    Nori US, Manoharan A, Yee J, Besarab A. Comparison of low-dose gentamicin with minocycline as catheter lock solutions in the prevention of catheter-related bacteremia. Am J Kidney Dis. 2006;48:596–605.CrossRefPubMedGoogle Scholar
  28. 28.
    Filiopoulos V, Hadjiyannakos D, Koutis I, et al. Approaches to prolong the use of uncuffed hemodialysis catheters: results of a randomized trial. Am J Nephrol. 2011;33:260–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Schilcher G, Scharnagl H, Horina J, et al. Trisodium citrate induced protein precipitation in haemodialysis catheters might cause pulmonary embolism. Nephrol Dial Transplant. 2012;27:2953–7.CrossRefPubMedGoogle Scholar
  30. 30.
    National Kidney Foundation KDOQI Work Group. KDOQI clinical practice guidelines and clinical practice recommendations for vascular access. Am J Kidney Dis. 2006;48:S176–322.CrossRefGoogle Scholar
  31. 31.
    Weijmer MC, Vervloet MG, ter Wee PM. Compared to tunneled cuffed haemodialysis catheters, temporary untunnelled catheters are associated with more complications already within 2 weeks of use. Nephrol Dial Transplant. 2004;19:670–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Ponikvar R, Buturović-Ponikvar J. Temporary hemodialysis catheters as a long-term vascular access in chronic hemodialysis patients. Ther Apher Dial. 2005;9:250–3.CrossRefPubMedGoogle Scholar
  33. 33.
    Pisoni RL, Young EW, Dykstra DM, Greenwood RN, Hecking E, Gillespie B, Wolfe RA, Goodkin DA, Held PJ. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int. 2002;61:305–16.CrossRefPubMedGoogle Scholar
  34. 34.
    Bunker JP, Bendixen HH, Murphy AJ. Hemodynamic effects of intravenously administered sodium citrate. N Engl J Med. 1962;266:372–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Franklin Correa Barcellos
    • 1
  • Bruno Pereira Nunes
    • 2
  • Luciana Jorge Valle
    • 1
  • Thiago Lopes
    • 1
  • Bianca Orlando
    • 1
  • Cintia Scherer
    • 1
  • Marcia Nunes
    • 1
  • Gabriela Araújo Duarte
    • 1
  • Maristela Böhlke
    • 1
  1. 1.Unidade de Diálise e Transplante Renal do Hospital Universitário São Francisco de PaulaUniversidade Católica de PelotasPelotasBrazil
  2. 2.Department of NursingFederal University of PelotasPelotasBrazil

Personalised recommendations