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van Oevelen M, Heggen BDC, Abrahams AC, Rotmans JI, Snoeijs MGJ, Vernooij RWM, van Buren M, Meijvis SCA. Central venous catheter-related complications in older haemodialysis patients: A multicentre observational cohort study. J Vasc Access 2023; 24:1322-1331. [PMID: 35360988 PMCID: PMC10714686 DOI: 10.1177/11297298221085225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/12/2022] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Central venous catheters (CVC) remain a commonly used vascular access option in haemodialysis, despite guidelines advising to preferably use arteriovenous fistulae. Compared to younger patients, the risk-benefit ratio of CVC in older patients might be more beneficial, but previous studies mainly focussed on catheter-related bacteraemia and/or assessed tunnelled CVC (TCVC) only. This study's aim was to compare all catheter-related infections and malfunctions in older patients with younger patients using all CVC subtypes. MATERIALS AND METHODS We used data from DUCATHO, a multicentre observational cohort study in The Netherlands. All adult patients in whom a CVC was placed for haemodialysis between 2012 and 2016 were included. The primary endpoint was the occurrence of catheter-related infections, comparing patients aged ⩾70 years with patients aged <70 years (reference). As secondary endpoints, catheter malfunctions and catheter removal due to either infection or malfunction were assessed. Using Cox proportional hazards and recurrent events modelling, hazard ratios (HR) with 95% confidence intervals (CI) were calculated with adjustment of prespecified confounders. Additionally, endpoints were assessed for non-tunnelled CVC (NTCVC) and TCVC separately. RESULTS A total of 1595 patients with 2731 CVC (66.5% NTCVC, 33.1% TCVC) were included. Of these patients, 1001 (62.8%) were aged <70 years and 594 (37.2%) ⩾70 years. No statistically significant difference was found for the occurrence of catheter-related infections (adjusted HR 0.80-95% CI 0.62-1.02), catheter malfunction (adjusted HR 0.94-95% CI 0.75-1.17) and catheter removal due to infection or malfunction (adjusted HR 0.94-95% CI 0.80-1.11). Results were comparable when assessing NTCVC and TCVC separately. CONCLUSION Patients aged ⩾70 to <70 years have a comparable risk for the occurrence of catheter-related infections and catheter malfunction. These findings may help when discussing treatment options with older patients starting haemodialysis and may inform the current debate on the best vascular access for these patients.
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Affiliation(s)
- Mathijs van Oevelen
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Boudewijn DC Heggen
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten GJ Snoeijs
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robin WM Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
| | - Sabine CA Meijvis
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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Weiss S, Qureshi M. Evaluating a Novel Hemodialysis Central Venous Catheter Cap in Reducing Bloodstream Infections: A Quality Improvement Initiative. Int J Nephrol Renovasc Dis 2021; 14:125-131. [PMID: 33953599 PMCID: PMC8091437 DOI: 10.2147/ijnrd.s304605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Central line-associated bloodstream infection (CLABSI) is the second leading cause of death in hemodialysis patients. Patients dialyzed via central venous catheters (CVCs) are more susceptible to vascular access-related bloodstream infection (VRBSI), sepsis, and mortality when compared to patients with other dialysis accesses. Patients and Methods A retrospective observational data analysis was conducted from 13 outpatient dialysis clinics in the United States to compare novel chlorhexidine-coated end caps to standard needlefree connectors for differences in CLABSI rates when utilizing CVCs for hemodialysis. There were two periods in this study: in the first study period over a 5-month period (May 2018 to September 2018), data were evaluated from a group of patients undergoing hemodialysis using chlorhexidine end-caps ('chlorhexidine group') as well as a group using standard needlefree connectors ('standard group'). An initial assessment found that a substantial CLABSI rate reduction was seen with use of chlorhexidine-coated end caps; therefore, most patients were switched to chlorhexidine by February 2019 and data continued to be collected till June 2019. The second study period spanned 9 months from October 2018 to June 2019. Results Across 13 dialysis centers, anonymized health records of 5934 patients who were dialyzed via CVCs between May 2018 and June 2019 were analyzed. The mean age was 61.3 and 47.1% of all patients were female. Study period one included 967 patients with chlorhexidine and 1044 patients with standard end caps, while there were 3647 chlorhexidine and 276 standard patients in the second period. The combined CLABSI rate in the chlorhexidine group was 0.09/1000 CVC days versus 0.63/1000 CVC days in the standard group (p<0.0001). Conclusion Chlorhexidine-coated CVC caps may provide a therapeutic improvement in CVC hemodialysis management.
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Affiliation(s)
- Steven Weiss
- Quality and Support Services, Atlantic Dialysis Management Services, Ridgewood, New York, USA
| | - Muhammad Qureshi
- Clinical Research, Mattoo & Bhat Medical Associates, P.C., College Point, New York, USA
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Heidempergher M, Sabiu G, Orani MA, Tripepi G, Gallieni M. Targeting COVID-19 prevention in hemodialysis facilities is associated with a drastic reduction in central venous catheter-related infections. J Nephrol 2021; 34:345-353. [PMID: 33369726 PMCID: PMC7768271 DOI: 10.1007/s40620-020-00900-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND In hemodialysis (HD) patients, central venous catheter (CVC) related bloodstream infections are a major cause of morbidity and mortality. Hygienic precautions are a key aspect of dialysis care for infection prevention, but they are not sufficient to completely avoid the occurrence of CVC related infections. During the COVID-19 pandemic, hygienic precautions for preventing viral transmission have been markedly reinforced. We evaluated their effects on CVC-related infection rates. METHODS An observational retrospective study was conducted in two hemodialysis units of the same institution treating 215 chronic hemodialysis patients, 71 of whom are currently (33%) using a CVC. In the CVC cohort, we compared data on catheter-related infection rates during the maximum spread of the COVID-19 pandemic in Italy (February to May 2020) with data from the same period of the previous year and with the whole of 2019. RESULTS In 2019, we recorded a catheter-related bloodstream infection (CRBSI) rate of 1.19 (95% CI 0.81-1.68)/1000 days [2.07 (95% CI 1.12-3.52)/1000 days in the Feb-May 2019 period] and a tunnel and exit-site infection rate of 0.82 (95% CI 0.51-1.24)/1000 days [1.04 (95% CI 0.41-2.15)/1000 days in the Feb-May 2019 period]. Infection rates drastically decreased during the COVID-19 pandemic, with just one catheter-related bloodstream infection being recorded. Catheter-related bloodstream infection rates showed a significant reduction to 0.20 (95% CI 0.01-0.9)/1000 days (p < 0.05 and p < 0.005 compared to 2019 and to Feb-May 2019, respectively) and a non-significant reduction in tunnel and exit-site infections to 0.6 (95% CI 0.15-1.6)/1000 days. CONCLUSIONS The observed 91% reduction in catheter-related bloodstream infections compared to the same period in 2019 [IRR 0.09 (95% CI 0.002-0.64)] and the 83% reduction compared to the whole of 2019 [IRR 0.17 (95% CI 0.004-1.009)] suggest that a stricter implementation of hygienic precautions in the dialysis setting can markedly improve the problem of CVC-related infections.
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Affiliation(s)
| | - Gianmarco Sabiu
- Nephrology Unit, ASST Fatebenefratelli Sacco, Milano, Italy
- School of Nephrology, Università di Milano, Milano, Italy
| | | | - Giovanni Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
| | - Maurizio Gallieni
- Nephrology Unit, ASST Fatebenefratelli Sacco, Milano, Italy.
- School of Nephrology, Università di Milano, Milano, Italy.
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università di Milano, via G.B. Grassi, 74, 20157, Milano, Italy.
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4
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Incidence and risk factors of sepsis in hemodialysis patients in the United States. J Vasc Surg 2020; 73:1016-1021.e3. [PMID: 32707386 DOI: 10.1016/j.jvs.2020.06.126] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/26/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Sepsis is one the most serious and life-threatening complication in patients with chronic hemodialysis (HD) access. Arteriovenous fistula (AVF) use is associated with a lower risk of infection. However, several prior studies identified significantly higher number of patients initiating HD using a catheter (HC) or arteriovenous graft (AVG). The aim of this study was to use a large national renal database to report the incidence and risk factors of sepsis in patients with end-stage renal disease (ESRD) initiating HD access using AVF, AVG, or HC in the United States. METHODS All patients with ESRD initiating HD access (AVF, AVG, HC) between January 1, 2006, and December 31, 2014, in United States Renal Data System were included. International Classification of Diseases, 9th edition-Clinical Modification diagnosis code (038x, 790.7) was used to identify patients who developed first onset of sepsis during follow-up. Standard univariate (Students t-test, χ2, and Kaplan-Meier) and multivariable (logistic/Cox regression) analyses were performed as appropriate. RESULTS A total of 870,571 patients were identified, of whom, 29.8% (n = 259,686) developed sepsis. HC (31.2%) and AVG (30.6%) were associated with a higher number of septic cases compared with AVF (22.9%; P < .001). The incident rate of sepsis was 12.66 episodes per 100 person-years. It was the highest among HC vs AVG vs AVF (13.86 vs 11.49 vs 8.03 per 100 person-years). Patients with sepsis were slightly older (mean age 65.09 ± 14.49 years vs 63.24 ± 15.17 years) and had higher number of comorbidities including obesity (40.7% vs 37.7%), congestive heart failure (36.6% vs 30.8%), peripheral arterial disease (15.6% vs 12.4%), and diabetes (59.6% vs 53.5%) (all P < .001). After adjusting for potential confounders, compared with AVF, patients with AVG (hazard ratio [HR], 1.35 [95% confidence interval [CI], 1.31-1.40) and HC (HR, 1.80 [95% CI, 1.77-1.84) were more likely to develop sepsis at 3 years (both P < .001). Compared with patients with no sepsis, sepsis was associated with a three-fold increase the odds of mortality (odds ratio, 3.16; 95% CI, 3.11-3.21; P < .001). Additionally, in patients who developed sepsis, AVF use was associated with significantly lower mortality compared with AVG and HC (73.7% vs 78.7% vs 78.0%; P < .001). After adjusting for significant covariates, compared with AVF, mortality at 1 year after sepsis was 21% higher in AVG (HR, 1.21; 95% CI, 1.15-1.28; P < .001) and nearly doubled in HC (HR, 1.94; 95% CI, 1.88-2.00; P < .001). CONCLUSIONS Sepsis risk in HD patients is clearly related to access type and is associated with dramatic increase in mortality. Initiating HD access with AVF to meet the National Kidney Foundation Kidney Disease Outcomes Quality recommendations should be implemented to reduce the incidence of sepsis and improve survival in patients with ESRD.
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5
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Terner Z, Long A, Reviriego-Mendoza M, Larkin JW, Usvyat LA, Kotanko P, Maddux FW, Wang Y. Seasonal and Secular Trends of Cardiovascular, Nutritional, and Inflammatory Markers in Patients on Hemodialysis. KIDNEY360 2020; 1:93-105. [PMID: 35372910 PMCID: PMC8809101 DOI: 10.34067/kid.0000352019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/13/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND All life on earth has adapted to the effects of changing seasons. The general and ESKD populations exhibit seasonal rhythms in physiology and outcomes. The ESKD population also shows secular trends over calendar time that can convolute the influences of seasonal variations. We conducted an analysis that simultaneously considered both seasonality and calendar time to isolate these trends for cardiovascular, nutrition, and inflammation markers. METHODS We used data from adult patients on hemodialysis (HD) in the United States from 2010 through 2014. An additive model accounted for variations over both calendar time and time on dialysis. Calendar time trends were decomposed into seasonal and secular trends. Bootstrap procedures and likelihood ratio methods tested if seasonal and secular variations exist. RESULTS We analyzed data from 354,176 patients on HD at 2436 clinics. Patients were 59±15 years old, 57% were men, and 61% had diabetes. Isolated average secular trends showed decreases in pre-HD systolic BP (pre-SBP) of 2.6 mm Hg (95% CI, 2.4 to 2.8) and interdialytic weight gain (IDWG) of 0.35 kg (95% CI, 0.33 to 0.36) yet increases in post-HD weight of 2.76 kg (95% CI, 2.58 to 2.97). We found independent seasonal variations of 3.3 mm Hg (95% CI, 3.1 to 3.5) for pre-SBP, 0.19 kg (95% CI, 0.17 to 0.20) for IDWG, and 0.62 kg (95% CI, 0.46 to 0.79) for post-HD weight as well as 0.12 L (95% CI, 0.11 to 0.14) for ultrafiltration volume, 0.41 ml/kg per hour (95% CI, 0.37 to 0.45) for ultrafiltration rates, and 3.30 (95% CI, 2.90 to 3.77) hospital days per patient year, which were higher in winter versus summer. CONCLUSIONS Patients on HD show marked seasonal variability of key indicators. Secular trends indicate decreasing BP and IDWG and increasing post-HD weight. These methods will be of importance for independently determining seasonal and secular trends in future assessments of population health.
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Affiliation(s)
- Zachary Terner
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, California
| | - Andrew Long
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | | | - John W. Larkin
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | - Len A. Usvyat
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York; and
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York
| | | | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, California
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6
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Viecelli AK, Howell M, Tong A, Teixeira-Pinto A, O’Lone E, Ju A, Craig JC, Hooi LS, Lee T, Lok CE, Polkinghorne KR, Quinn RR, Vachharajani TJ, Vanholder R, Zuo L, Tordoir J, Pecoits-Filho R, Yuo T, Kopperschmidt P, Smith R, Irish AB, Mori TA, Pascoe EM, Johnson DW, Hawley CM. Identifying critically important vascular access outcomes for trials in haemodialysis: an international survey with patients, caregivers and health professionals. Nephrol Dial Transplant 2019; 35:657-668. [DOI: 10.1093/ndt/gfz148] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/18/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Vascular access outcomes reported across haemodialysis (HD) trials are numerous, heterogeneous and not always relevant to patients and clinicians. This study aimed to identify critically important vascular access outcomes.
Method
Outcomes derived from a systematic review, multi-disciplinary expert panel and patient input were included in a multilanguage online survey. Participants rated the absolute importance of outcomes using a 9-point Likert scale (7–9 being critically important). The relative importance was determined by a best–worst scale using multinomial logistic regression. Open text responses were analysed thematically.
Results
The survey was completed by 873 participants [224 (26%) patients/caregivers and 649 (74%) health professionals] from 58 countries. Vascular access function was considered the most important outcome (mean score 7.8 for patients and caregivers/8.5 for health professionals, with 85%/95% rating it critically important, and top ranked on best–worst scale), followed by infection (mean 7.4/8.2, 79%/92% rating it critically important, second rank on best–worst scale). Health professionals rated all outcomes of equal or higher importance than patients/caregivers, except for aneurysms. We identified six themes: necessity for HD, applicability across vascular access types, frequency and severity of debilitation, minimizing the risk of hospitalization and death, optimizing technical competence and adherence to best practice and direct impact on appearance and lifestyle.
Conclusions
Vascular access function was the most critically important outcome among patients/caregivers and health professionals. Consistent reporting of this outcome across trials in HD will strengthen their value in supporting vascular access practice and shared decision making in patients requiring HD.
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Affiliation(s)
- Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Children’s Hospital at Westmead, Sydney, NSW, Australia
| | | | - Emma O’Lone
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Angela Ju
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Lai-Seong Hooi
- Department of Medicine and Haemodialysis Unit, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
- Section of Nephrology, Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Charmaine E Lok
- Division of Nephrology, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, VC, Australia
- Department of Medicine, Monash University, Melbourne, VC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VC, Australia
| | - Robert R Quinn
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Tushar J Vachharajani
- Department of Nephrology & Hypertension, Glickman Urological & Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Raymond Vanholder
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Li Zuo
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Jan Tordoir
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
| | | | - Theodore Yuo
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Rob Smith
- Nightcliff Renal Unit, Darwin, NT, Australia
| | - Ashley B Irish
- Department of Nephrology, Fiona Stanley Hospital, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Trevor A Mori
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
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Brown RS, Brickel K, Davis RB. Two-Year Observational Study of Bloodstream Infection Rates in Hemodialysis Facility Patients with and without Catheters. Clin J Am Soc Nephrol 2018; 13:1381-1388. [PMID: 30194227 PMCID: PMC6140562 DOI: 10.2215/cjn.13551217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 06/20/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Bloodstream infection rates of patients on hemodialysis with catheters are greater than with other vascular accesses and are an important quality measure. Our goal was to compare relative bloodstream infection rates of patients with and without catheters as a quality parameter among the facilities providing hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used CROWNWeb and National Healthcare Safety Network data from all 179 Medicare facilities providing adult outpatient hemodialysis in New England for >6 months throughout 2015-2016 (mean, 12,693 patients per month). There was a median of 60 (interquartile range, 43-93) patients per facility, with 17% having catheters. RESULTS Among the five batch-submitting dialysis organizations, the bloodstream infection rate in patients with a catheter in four organizations had adjusted risk ratios of 1.44 (95% confidence interval, 1.07 to 1.93) to 1.91 (95% confidence interval, 1.39 to 2.63) times relative to the reference dialysis provider group (P<0.001). The percentage of catheters did not explain the difference in bloodstream infection rates among dialysis provider organizations. The bloodstream infection rates in patients with a catheter were negatively correlated with the facility's proportion of this patient group. Facilities with <10%, 10%-14.9%, 15%-19.9%, and ≥20% catheter patients had bloodstream infection rates of 4.4, 2.2, 1.9, and 1.5 per 100 patient-months, respectively, in that patient group (adjusted P<0.001). This difference was not seen in patients without catheters. There was no effect of facility patient census or season of the year. CONCLUSIONS A study of the adult outpatient hemodialysis facilities in New England in 2015-2016 found that four dialysis provider groups had significantly higher bloodstream infection rates in patients with a catheter than the best-performing dialysis provider group. Hemodialysis facilities with lower proportions of patients with a catheter have significantly higher bloodstream infection rates in this patient group than facilities with >20% catheters, a finding that did not explain the difference among provider organizations.
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Affiliation(s)
| | | | - Roger B. Davis
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and
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8
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Nakashima A, Ohkido I, Yokoyama K, Mafune A, Urashima M, Yokoo T. Associations Between Low Serum Testosterone and All-Cause Mortality and Infection-Related Hospitalization in Male Hemodialysis Patients: A Prospective Cohort Study. Kidney Int Rep 2017; 2:1160-1168. [PMID: 29270524 PMCID: PMC5733882 DOI: 10.1016/j.ekir.2017.07.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/13/2017] [Accepted: 07/24/2017] [Indexed: 01/07/2023] Open
Abstract
Introduction Infectious diseases are the second highest cause of death in patients on dialysis. In addition, testosterone deficiency or hypogonadism is prevalent in dialysis patients. However, to our knowledge, no studies have investigated the association between testosterone levels and infectious events. We aimed to evaluate whether serum testosterone levels are associated with infection-related hospitalization in male hemodialysis patients in a prospective cohort study. Methods We divided the study population into 3 groups based on serum testosterone levels. Associations between testosterone levels and clinical outcomes of infection-related hospitalization, all-cause mortality, and cardiovascular disease (CVD) events were analyzed using the Cox proportional hazard model. Results Nine hundred two male patients were enrolled and followed up for a median of 24.7 months. Their mean ± SD age was 63.4 ± 11.8 years, and their median (interquartile range) of total testosterone was 11.7 nmol/l (7.9–14.9 nmol/l). During follow-up, 123 participants died. Infection-related hospitalization and CVD events occurred in 116 and 151 patients, respectively. Infection-related hospitalization was more frequent in the lower testosterone tertile than in the higher testosterone tertile (hazard ratio [HR]: 2.12; 95% confidence interval [CI]: 1.18–3.79; P = 0.01) in adjusted models. Moreover, all-cause mortality was significantly greater in the lower testosterone tertile than in the higher testosterone tertile in adjusted analysis (HR: 2.26; 95% CI: 1.21–4.23; P = 0.01). In contrast, there were no significant differences in CVD events by testosterone level. Discussion Low levels of testosterone may be associated with higher rates of infection-related hospitalization and all-cause mortality in male hemodialysis patients.
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Affiliation(s)
- Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan.,Division of Molecular Epidemiology, Jikei University School of Medicine, Tokyo, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Keitaro Yokoyama
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Aki Mafune
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan.,Division of Molecular Epidemiology, Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuyoshi Urashima
- Division of Molecular Epidemiology, Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
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9
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Kosa SD, Gafni A, House AA, Lawrence J, Moist L, Nathoo B, Tam P, Sarabia A, Thabane L, Wu G, Lok CE. Hemodialysis Infection Prevention Protocols Ontario-Shower Technique (HIPPO-ST): A Pilot Randomized Trial. Kidney Int Rep 2017; 2:228-238. [PMID: 29142959 PMCID: PMC5678668 DOI: 10.1016/j.ekir.2016.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/28/2016] [Accepted: 11/01/2016] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION We developed the Hemodialysis Infection Prevention Protocols Ontario-Shower Technique (HIPPO-ST) to permit hemodialysis (HD) patients with central venous catheters (catheters) to shower without additional infection risk. Our primary objective was to determine the feasibility of conducting a parallel randomized controlled trial (RCT) to evaluate the impact of HIPPO-ST on catheter-related bacteremia (CRB) in adult HD patients. METHODS Adult HD patients using catheters were recruited from 11 HD units. Patients were randomized to receive HIPPO-ST or standard care and were followed up for 6 months. Only CRB-outcome assessors were blinded. For the study to be considered feasible, 4 of 5 feasibility outcomes, each with its own statistical threshold for success, must have been achieved. RESULTS A total of 68 patients were randomized (33 HIPPO-ST and 35 control) and were followed up to 6 months. Of 5 measures of feasibility, 4 were achieved: (1) accurate CRB rate documented (threshold: κ level >0.80); (2) 97.8% (279/285) of satellite HD patients with catheters were screened (threshold: >95%); (3) 88% (23/26) in the HIPPO-ST arm were successfully educated by 6 months (threshold: >80%); and (4) 0% (0/29) patients in the control arm were "contaminated," that is, using HIPPO-ST (threshold: <5%). However, only 44.2% (72/163) of eligible patients consented to participate (threshold: >80%). The rate of CRB was similarly low in HIPPO-ST and control groups (0.68 vs. 0.88/1000 catheter days). DISCUSSION This HIPPO-ST pilot study demonstrated the feasibility of the larger HIPPO-ST study, especially given the high levels of education success with the HIPPO-ST arm and the low levels of contamination in the control arm.
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Affiliation(s)
- S. Daisy Kosa
- University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Amiram Gafni
- University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | - Louise Moist
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Paul Tam
- The Scarborough Hospital, Scarborough, Ontario, Canada
| | | | | | - George Wu
- Credit Valley Hospital, Mississauga, Ontario, Canada
| | - Charmaine E. Lok
- University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
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Wetmore JB, Gilbertson DT, Liu J, Collins AJ. Improving Outcomes in Patients Receiving Dialysis: The Peer Kidney Care Initiative. Clin J Am Soc Nephrol 2016; 11:1297-1304. [PMID: 27006497 PMCID: PMC4934850 DOI: 10.2215/cjn.12981215] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The past decade has witnessed a marked reduction in mortality rates among patients receiving maintenance dialysis. However, the reasons for this welcome development are uncertain, and greater understanding is needed to translate advances in care into additional survival gains. To fill important knowledge gaps and to enable dialysis provider organizations to learn from one another, with the aim of advancing patient care, the Peer Kidney Care Initiative (Peer) was created in 2014 by the chief medical officers of 14 United States dialysis provider organizations and the Chronic Disease Research Group. Areas of particular clinical importance were targeted to help shape the public health agenda in CKD and ESRD. Peer focuses on the effect of geographic variation on outcomes, the implications of seasonality for morbidity and mortality, the clinical significance of understudied disorders affecting dialysis patients, and the debate about how best to monitor and evaluate progress in care. In the realm of geovariation, Peer has provided key observations on regional variation in the rates of ESRD incidence, hospitalization, and pre-ESRD care. Regarding seasonality, Peer has reported on variation in both infection-related and non-infection-related hospitalizations, suggesting that ambient environmental conditions may affect a range of health outcomes in dialysis patients. Specific medical conditions that Peer highlights include Clostridium difficile infection, which has become strikingly more common in patients in the year after dialysis initiation, and chronic obstructive pulmonary disease, the treatments for which have the potential to contribute to sudden cardiac death. Finally, Peer challenges the nephrology community to consider alternatives to standardized mortality ratios in assessing progress in care, positing that close scrutiny of trends over time may be the most effective way to drive improvements in patient care.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota; and
| | - David T. Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Allan J. Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Soi V, Moore CL, Kumbar L, Yee J. Prevention of catheter-related bloodstream infections in patients on hemodialysis: challenges and management strategies. Int J Nephrol Renovasc Dis 2016; 9:95-103. [PMID: 27143948 PMCID: PMC4846073 DOI: 10.2147/ijnrd.s76826] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Catheter-related bloodstream infections are a significant source of morbidity and mortality in the end-stage renal disease population. Although alternative accesses to undergoing renal replacement therapy exist, many patients begin hemodialysis with a dialysis catheter due to logistic and physiologic factors involved in arteriovenous fistula creation and maturation. Colonization of catheters via skin flora leads to the production of biofilm, which acts as a reservoir for virulent bacteria. Preventative therapies center on appropriate catheter maintenance, infection control measures, and early removal of devices as patients transition to other access. Despite best efforts, when conservative measures fail to prevent infections in a high-risk population, antimicrobial lock therapy should be considered as an option to combat catheter-related bloodstream infections.
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Affiliation(s)
- Vivek Soi
- Division of Nephrology and Hypertension, Henry Ford Health System, Detroit, MI, USA
| | - Carol L Moore
- Division of Nephrology and Hypertension, Henry Ford Health System, Detroit, MI, USA
| | - Lalathakasha Kumbar
- Division of Nephrology and Hypertension, Henry Ford Health System, Detroit, MI, USA
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Health System, Detroit, MI, USA
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Gilbertson DT, Wetmore JB. Infections Requiring Hospitalization in Patients on Hemodialysis. Clin J Am Soc Nephrol 2015; 10:2101-3. [PMID: 26567371 DOI: 10.2215/cjn.10891015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- David T Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and
| | - James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; and Department of Medicine, Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota
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Chen WT, Huang HR, Lim KP, Tseng HC, Shih CC. The correlation between seasonality and peripherally inserted central catheter-related infections in cancer patients. J Infect 2015; 71:410-2. [PMID: 25987475 DOI: 10.1016/j.jinf.2015.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/09/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Wei-Ting Chen
- Division of Infectious Diseases, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan; Division of Infection Control, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan.
| | - Hsin-Ru Huang
- Division of Infection Control, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan
| | - Kim-Peng Lim
- Division of Infectious Diseases, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan; Division of Infection Control, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan
| | - Hsiu-Chin Tseng
- Division of Infectious Diseases, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan; Division of Infection Control, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan
| | - Chiang-Ching Shih
- Division of Infectious Diseases, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan; Division of Infection Control, Koo Foundation Sun Yat-Sen Cancer Center, Taipei 112, Taiwan
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