Inserting tunnelled hemodialysis cathetersusing elective guidewire exchange from

nontunnelled catheters: Is there a greaterrisk of infection when compared with

new-site replacement?

Jonathan CASEY, Jonathan DAVIES, Amanda BALSHAW-GREER, Nichola TAYLOR,

Alexander V. CROWE, Peter MCCLELLAND

Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, Wirral, Merseyside, UK

AbstractThe objective is to evaluate bacteremia outcomes and survival rates when using guidewire exchange

to place tunnelled hemodialysis catheter (THDC) compared with a new-site replacement. Retrospec-

tively, all patients were identified who received a THDC between January 1, 2000 and January 1,

2007. Any THDC having received antibiotic line locks or tunnel-to-tunnel exchange were excluded.

This left 408 THDC placed in 329 patients: 46 guidewire exchange, 362 new-site replacement.

Bacteremia rate from the new-site insertion group was 3.0 per 1000 catheter days, the guidewire

exchange group demonstrated a rate of 2.8 per 1000 catheter days. Local infection rates did not

differ between the groups at 1.2 per 1000 catheters days. The actuarial catheter survival rates using

Kaplan-Meier survival analysis demonstrated no difference between the 2 groups. The placing of

tunnelled cuffed hemodialysis catheters to replace temporary catheters using a guidewire exchange

did not contribute to further episodes of sepsis and has the advantage of preserving venous access

and minimizing invasive procedures for the patient.

Key words: Catheter, hemodialysis, bacteremia, tunnelled

INTRODUCTION

Tunnelled hemodialysis catheters (THDC) are becomingincreasingly commonplace when seeking access for

hemodialysis treatment. Their importance to the dialysis

patient cannot be overstated. Insertion, use, and care may

have an influence on the patient’s morbidity and mortality

particularly with respect to flow inadequacies and infec-

tion.1 Placement technique and management of further

complications are a prerequisite for an individual or

department seeking to place these lines. Temporary

uncuffed catheters are commonly used when immediate

hemodialysis access is required in an acute situation or

when primary access has failed. However, the longer

these lines are left in place, the higher the rate of infec-

tion.2 The National Kidney Foundation Kidney DiseaseOutcomes Quality Initiative3 (K/DOQI) guidelines rec-

ommend that internal jugular catheters should not be left

in place longer than 3 weeks. The K/DOQI guidelines also

indicate that the use of guidewire exchange is

a promising future therapy when dealing with infected

lines. It has the advantage of preserving the venous access

site and is only 1 procedure as opposed to 2, i.e., removal

and subsequent reinsertion. Robinson et al.4 furthercomments that using new-site insertion may compromise

future long-term upper extremity access and can lead to

Correspondence to: J. Casey, Department of Nephrology,Wirral University Teaching Hospital NHS Foundation, Ward31 (Nephrology), Upton, Wirral, Merseyside CH49 5PE, UK.E-mail: jonathan.casey@whnt.nhs.uk

Hemodialysis International 2008; 12:52–54

r 2008 The Authors. Journal compilation r 2008 International Society for Hemodialysis52

central venous stenosis. This study asks whether replac-ing a noncuffed temporary line for a cuffed THDC using

guidewire exchange increases catheter associated bacter-

emia rates when compared with new-site insertion.

MATERIALS AND METHODS

A record of all cuffed and noncuffed lines placed within a

3-centered renal unit is recorded on a single SPSS (Sta-

tistical Package for the Social Sciences) package for rou-tine audit scrutiny. Retrospective data retrieval from

January 1, 2000 to January 1, 2007 revealed a total of

464 cuffed lines placed of which 418 were new-site and

56 THDC placed using guidewire exchange from a non-

cuffed catheter. The phenomenon of antibiotic lock to

combat bacteremia and salvage catheters has recently

gained popularity with reported success.5,6 To ensure va-

lidity those catheters that had received such a ‘‘line lock’’in both groups were excluded from the study, along with

tunnel-to-tunnel exchange, thus leaving 362 new-site in-

sertion and 46 guidewire exchange catheters for inclusion

(total 408). Any evidence of an exit site infection pre-

cluded the noncuffed catheter from guidewire exchange,

the noncuffed catheter was removed and a THDC

placed as a new-site insertion. Tunnelled hemodialysis

catheter-related infection was prospectively evaluated forguidewire exchange and new-site insertion and analyzed

relative to time to first infection and bacteremia rate per

1000 catheter days.

Bacteremia (for the purposes of this study) was diag-

nosed by positive blood cultures from either lumen of the

THDC and if possible, from a peripheral vein. Blood was

drawn on suspicion of a THDC systemic infection, i.e.,

pyrexia, rigors, elevated C-reactive protein, and raisedWCC. If cultures were negative, even with associated raised

markers, this did not qualify as a bacteremic episode.

Routine practice for new-site placement involves

THDC insertion under ultrasound guidance by an expe-

rienced operator using strict aseptic technique (Tesio

catheter-medComp, Harleysville, PA, U.S.A.). The cathe-

ter exit site for all lines was inspected at each dialysis

session and cleaned with a 10% alcoholic povidine-iodinesolution after each dialysis. Intradialytic anticoagulation

is standardized: 5000 U unfractionated heparin per mL to

the length of the THDC lumens.

RESULTS

The new-site insertion accounted for 88.7% (362) of the

total THDC placed leaving 11.3% (46) in the guidewire

exchange group. Technical success for guidewire ex-

change was 100%. Age distribution across the whole

group was: youngest=20 years old; oldest=94 years

old; mean age=56 years old. Gender distribution across

the whole cohort was 269 male (65.9%) and 139 female(34.1%). Within groups: guidewire exchange=30 male,

16 female; new-site=239 male, 123 female. Diabetic

patients accounted for 25.5% (104) of the total. Surpris-

ingly, only 8 from 46 of the guidewire exchange group

were diabetic (11%). The bacteremia rate of the THDC

for both groups was analyzed as per 1000 catheter days

and total catheter survival using Kaplan-Meier survival

analysis (Figure 1).Systemic infection rates from the new-site insertion

group was 3.0 per 1000 catheter days; the guidewire ex-

change group demonstrated a rate of 2.8 per 1000 cath-

eter days. Local infection rates did not differ between the

groups at 1.2 per 1000 catheters days. The time to first

infection in the guidewire exchange group demonstrated

a mean of 72 days and median of 64 days, and in the

new-site replacement group, a mean of 124 days but amedian of 66 days.

Limitations

This is a retrospective study and there is a clear numerical

difference between groups with a smaller number of

catheters exchanged over guidewire. It would have been

useful to include as a separate group those THDC receiv-

ing antibiotic line locks to avoid bias; unfortunately, this

data was not available.

60483624120

time (months)

1.0

0.8

0.6

0.4

0.2

0.0

Cu

m c

ath

eter

su

rviv

al %

-Guidewire exchange (no.46)

-New-site insertions (no.358)

Figure 1 Kaplan-Meier survival curve comparing electiveguidewire exchange with new-site tunnelled hemodialysiscatheter insertions.

New-site replacement or guidewire exchange?

Hemodialysis International 2008; 12:52–54 53

DISCUSSION

While it is difficult to estimate, Combe et al.7,8 suggest

that between 20% and 60% of new end-stage renal dis-

ease patients start hemodialysis with a temporary cathe-

ter, and approximately 23% of patients receive long-term

treatment via a THDC. Thus, it is reasonable to postulatethat many patients are converted from temporary un-

cuffed catheters to THDCs.

Many studies have commented on the successful out-

come of guidewire exchange in combating catheter-asso-

ciated bacteremia for noncuffed catheters.4,9,10 However,

scant evidence exists for elective guidewire exchange

from temporary uncuffed catheters to THDC and their

relationship to bacteremia rates when compared with anew-site insertion. There are advantages to placing a line

in the same access site such as avoiding multiple vein

occlusions, and by using guidewire exchange you are

preserving other veins for future use. Another advantage

pointed out by Gersch11 is that the patient only under-

goes 1 invasive procedure instead of 2 or more proce-

dures with the removal and delayed reinsertion strategy.

This study demonstrated similar rates of bacteremia be-tween guidewire exchanged THDC and THDC placed to a

new site. With similar survival rates for the newly inserted

catheter observed, the use of this strategy does not seem

to increase the incidence of infectious complications,

although it is interesting to note that the Vascular Access

Society guidelines12 recommend against the use of

guidewire exchange citing the possibility of ‘‘delayed sep-

tic metastasis or endocarditis.’’ Clearly more confirmationis required by prospective controlled trials, and while

all THDC continue to carry a risk of infection, perhaps

more focus should be on early referral to vascular

surgery.

CONCLUSION

Guidewire exchange caused no increase in bacteremia

episodes and provided similar longevity to new-siteplacements. The procedure is safe and easy to perform

and has the advantage of preserving venous access and

minimizing invasive procedures for the patient.

Manuscript received May 2007; revised June 2007.

REFERENCES

1 Davies J, Casey J, Li C, Crowe AV, McClelland P.Restoration of flow following hemodialysis catheterthrombus. Analysis of rt-PA infusion in tunnelleddialysis catheters. J Clin Pharm Ther. 2004; 29:517–520.

2 Kairaitis LK, Gottlieb T. Outcome and complications oftemporary hemodialysis catheters. Nephrol Dial Trans-plant. 1999; 14:1710–1714.

3 K/DOQI clinical practice guidelines for chronic kidneydisease: Evaluation, classification and stratification.Kidney disease outcomes quality initiative. Am J KidneyDis. 2002; 39(Suppl 1):S1–S246.

4 Robinson D, Suhocki P, Schwab SJ, et al. Treatment ofinfected tunnelled venous access hemodialysis catheterswith guidewire exchange. Kidney Int. 1998; 53:1792–1794.

5 Kim SH, Kang CI, Kim HB, et al. Outcomes of Hickmancatheter salvage in febrile neutropenic cancer patientswith Staphylococcus aureus bacteremia. Infect Control HospEpidemiol. 2003; 24:897–904.

6 Vercaigne LM, Zelenitsky SA, Findlay I, Bernstein K,Penner SB. An in vitro evaluation of the antibiotic/heparin lock to sterilize central venous hemodialysiscatheters. J Antimicrob Chemother. 2002; 49:693–696.

7 Combe C, Pisoni RL, Port FK, et al. Dialysis outcomesand practice patterns study: Data on the use of centralvenous catheters in chronic hemodialysis. Nephrologie.2001; 22:379–384.

8 Pisoni RL, Young EW, Dykstra DM, et al. Vascular accessuse in Europe and the United States: Results from theDOPPS. Kidney Int. 2006; 61:305–316.

9 Mokrzycki MH, Singhal A. Cost-effectiveness of threestrategies of managing tunnelled, cuffed hemo-dialysis catheters in clinically mild or asymptomaticbacteremias. Nephrol Dial Transplant. 2002; 17:2196–2203.

10 Shaffer D. Catheter-related sepsis complicating longterm, tunnelled central venous dialysis catheters: Man-agement by guidewire exchange. Am J Kidney Dis. 1995;25:593–596.

11 Gersch MS. Treatment of dialysis catheter infections in2004. J Vasc Access. 2004; 5:99–108.

12 Sidawy AN, Gray R, Besarab A, et al. Recommendedstandards for reports dealing with arteriovenous hemo-dialysis access. J Vasc Surg. 2002; 35:603–610.

Casey et al.

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