Effective Use of Alteplase for Occluded Tunneled Venous Catheter in Hemodialysis Patients

Abstract

Despite their propensity for significant infectious and mechanical complications, tunneled central venous catheters (CVCs) have become a common means of vascular access in the world for patients requiring chronic hemodialysis for end-stage renal disease. The objective of this study was to explore if cryopreserved solutions of the thrombolytic agent alteplase could be used as an effective, safe, and economically reasonable alternative in hemodialysis patients with occluded tunneled CVC. Patients requiring chronic hemodialysis and presenting with occluded tunneled CVC received a sufficient volume of the alteplase solution to fill the occluded catheter. To make alteplase economically feasible, it was diluted to 1-mg/mL aliquots and they were stored at -20°C until use. Eighty-one patients accounting for 179 attempted clearances were assessable for efficacy. One hundred forty-seven (82.1%) of the 179 catheter clearance attempts resulted in successful catheter clearance after one dose. Twenty-seven (15.1%) of all occluded CVCs were successful after two doses whereas five (2.8%) were not. No adverse events were reported. Cryopreserved 1-mg/mL aliquots of alteplase are safe and effective in the clearance of occluded CVC for hemodialysis patients.

Occluded Tunneled Venous Catheter in Hemodialysis Patients: Risk Factors and Efficacy of Alteplase

“…Our study showed that 87% of the 815 catheter attempts resulted in successful catheter clearance after the use of alteplase: 77% after one dose and 10% after the second dose; only 13% did not result in success. Similar results were reported by other authors in oncology and HD patients .…”

Peritoneal dialysis as the first dialysis treatment option initially unplanned

“…15,17,20 Clinical trials comparing unplanned HD vs. unplanned PD starts will hardly ever be carried out because of their ethical implications. Therefore, observational studies of good quality performed in developed and developing nations must be carried out to further support urgent-start PD.…”

“…13,14 PeritoneAl diAlysis As the method of choice to urgently stArt therAPy Unplanned start dialysis, also known as urgent-start dialysis, may be defined as the initiation of HD without a definitive functioning vascular access -i.e., treatment is started with a CVC -or the start of PD within seven days of the implantation of a catheter. 15,16,17 Iversen et al 15 retrospectively reviewed the Danish Nephrology Registry (2008)(2009)(2010)(2011) and reported that 50% of the incident patients on RRT had unplanned therapy starts. In Brazil, approximately 60% of the incident patients on RRT do not have a definitive access and are treated with a CVC.…”

“…In the dialysis center of the University Hospital of the Medical School of Botucatu (Hospital Universitário da Faculdade de Medicina de Botucatu), the numbers are even more alarming: more than 90% of the incident patients have unplanned dialysis starts and 50% of the prevalent patients do not have a definitive functioning vascular access and are treated with tunneled CVCs. 16,17 In a recently published paper, Lok et al reported that about a third of the patients worldwide have unplanned RRT starts, an event that makes the discussions around the development of diagnosis and treatment, including the choice of mode of dialysis and the implantation of a dialysis access, more challenging to the health care team. 18 PD has been seen as a viable and safe alternative to HD in unplanned dialysis starts in developed and developing nations, nurturing the growth of PD programs.…”

Peritoneal Dialysis as an option for unplanned initiation of chronic dialysis

“…[7][8][9] Unplanned dialysis may be defined as the start of HD without a functioning definitive vascular access (AVF), i.e., using a CVC, or as the start of PD within less than 7 days after its implantation. [12][13][14] Ivarsen et al 12 retrospectively reviewed the Danish Nephrology Registration from 2008 to 2011 and found that 50% of incident patients on RRT started it in an unplanned manner. In Brazil, approximately 60% of incident patients on RRT have no definitive access and need to be treated through CVC.…”