Minimizing Hemodialysis Catheter Dysfunction: An Ounce of Prevention

Table 1

Studies evaluating therapies for the prevention of HD catheter dysfunction.

	Reference	Study design N	Treatment groups			Outcome	Effect	P
Catheter locking agents
Heparin	Thomas, 2007 [7]	P; 𝑁=273	Heparin; (1000 U/mL)		Heparin (10 000 U/mL)	Catheter dysfunction (per 1000 HD sessions)	Low H/high H; 6.7 versus 7.6	NS
						Thrombolytic therapy (per 1000 HD session)	Low H/high H; 26.6 versus 8.2	<0.001
Heparin	Holley, 2007 [8]	R; 𝑁=64	Heparin; (1000 U/mL)		Heparin (10 000 U/mL)	Thrombolytic therapy (per 6 months)	Low H/high H; 63% versus 31%	<0.001
Citrate (4%)	Buturovic, 1998 [9]	RCT; 𝑁=30	Citrate 4%	Heparin; (1666 U/mL)	Polygeline (3.5%)	Catheter survival (days)	C/H/P 51/23/32	<0.01
Citrate (4%)	Lok, 2007 [10]	P; 𝑁=250	Citrate; 4%		Heparin (5000 U/mL)	Thrombolytic rate (per 1000 days)	C/H 3.3 versus 5.5	<0.001
						Catheter removal for poor flow (per 1000 days)	C/H 1.65 versus 2.98	0.042
Citrate (4%)	Grudzinski, 2007 [11]	R; 𝑁=307	Citrate*; 4%		Heparin** (10 000 U/mL)	Thrombolytic rate (per 1000 days)	C/H 3.23 versus 4.10	0.07
						Catheter removal for poor flow (per 1000 days)	C/H 1.88 versus 1.81	NS
Citrate (4%)	MacRae, 2008 [12]	RCT; 𝑁=61	Citrate; 4%		Heparin (5000 U/mL)	Thrombolytic therapy; (6 months)	C/H 41% versus 45%	NS
Citrate (5%)	Hendrickx, 2001 [13]	RCT; 𝑁=19	Citrate; 5%		Heparin (5000 U/mL)	Thrombolytic therapy (per HD session)	C/H 8% versus 1%	NS
						Aspiration of thrombus (6 months)	C/H 14% versus 7%	<0.001
Citrate (30%)	Stas, 2001 [14]	P; 𝑁=11	Citrate; 30%		Heparin (5000 U/mL)	Aspiration of thrombus	C=H	NS
Citrate (30%)	Weijmer, 2005 [15]	RCT; 𝑁=291	Citrate; 30%		Heparin (5000 U/mL)	Thrombolytic Therapy (6 months)	C/H 47% versus 44%	NS
						Catheter removal for poor flow (per 1000 days)	C/H 3.2 versus 3.6	NS
Citrate (47%)	Bayes 1999 [16]	P; 𝑁=10	Citrate,; 46.7%		Heparin (5000 U/mL)	Blood flow rate	C=H	NS
Citrate (47%)	Power, 2009 [17]	RCT; 𝑁=232	Citrate,; 46.7%		Heparin (5000 U/mL)	Thrombolytic therapy (per 1000 days)	C/H; 8.2 versus 4.3	<0.001
Tissue plasminogen activator	Schenk, 2000 [18]	P; 𝑁=12	r-TPA (1 mg/mL interdialytic lock)		Heparin (1000 U/mL)	Blood flow rate mL/min	TPA/H; 237 versus 208	0.001
						Thrombolytic therapy (4 months)	TPA/H; 0% versus 20%	—
Tissue plasminogen activator	Gittins, 2007 [19]	P; 𝑁=9	r-TPA (1 mg/mL interdialytic lock)		Heparin (1000 U/mL)	Aspiration of thrombus	H > rTPA: O.R. 2.4	0.001
						Clot volume	H > rTPA: O.R.  =  1.9	<0.001
Tissue plasminogen activator	Hemmelgarn, 2011 [20]	RCT; 𝑁=225	r-TPA (1 mg/mL interdialytic lock midweek heparin 5000 U/Ml in other 2 sessions)		Heparin (5000 U/mL)	Catheter malfunction	rTPA  <  heparin; HR 1.91	0.02
						Catheter-related bacteremia (episodes/1000 catheter days)	rTPA<Heparin; 0.40 versus 1.37	0.02
Modified catheters
Heparin-; coated; catheters	Clark, 2009 [21]	R; 𝑁=88	Heparin-coated catheter (+ heparin lock 5000 U/mL)		Noncoated catheter (+ heparin lock 5000 U/mL)	Primary patency (at 3 months)	HCC/NCC; 82% versus 76%	NS
						Thrombosis rate (per 1000 days)	HCC/NCC; 0.8 versus 0.4	NS
Heparin-; coated; catheters	Jain, 2009 [22]	R; 𝑁=175	Heparin-coated Catheter (+ Hepain lock 5000 U/mL)		Non-coated Catheter (+ Hepain lock 5000 U/mL)	Cumulative catheter survival (at 6 months)	HCC/NCC; 48% versus 41%	NS
						Thrombolytic therapy (per 1000 days)	HCC/NCC; 1.8 versus 1.8	NS
Oral agents
Warfarin (mini dose)	Mokrzycki, 2001 [23]	RCT; 𝑁=85	Warfarin (1 mg)		Placebo	Primary catheter patency (at 1 year)	W/P; 58% versus 48%	NS
						Assisted primary catheter patency (at 1 year)	W/P; 20% versus, 18%	NS
Warfarin (low intensity)	Wilkieson, 2011 [24]	RCT; 𝑁=174	Warfarin (INR 1.5–1.9)		Placebo	Primary catheter patency	W/P; 46% versus 47%	NS
						Catheter removal for dysfunction	W/P; HR  =  0.87	NS
Warfarin (low intensity)	Zellweger, 2005 [25]	P; 𝑁=65	Warfarin (INR 1.5–2.0) (high-risk pts)		Controls (low-risk pts)	Primary catheter patency (at 9 months)	Anticoagulation; (adequate versus inadequate); 47% versus 8%	0.01
Warfarin; (high intensity)	Obialo, 2003 [26]	P; 𝑁=63	Aspirin 325 mg/d	Warfarin (INR 2-3)	Control	Primary catheter patency (number of days)	A/W/C; 114/111/68	<0.001
						Catheter survival (at 4 months)	A/W/C; 91%/73%/29%	<0.001
Warfarin; (medium intensity); and ticlodipine	Coli, 2006 [27]	RCT; 𝑁=144	Primary prevention Warfarin (INR 1.8–2.5) + ticlodipine 250 mg/day (1°W + T)		Secondary prevention (INR 1.8–2.5) + Ticlodipine 250 mg/day (2°W + T)	Catheter dysfunction (1 year)	1°W + T/2°W + T; 12% versus 52%	<0.01
						Catheter dysfunction (events per pt/year)	PWT/RWT; 0.16 versus 1.65	<0.001