Skip to main content

Advertisement

SpringerLink
Log in

Sodium citrate versus saline catheter locks for non-tunneled hemodialysis central venous catheters in critically ill adults: a randomized controlled trial

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Purpose

Sodium citrate has antibacterial and anticoagulant properties that are confined to the catheter when used as a catheter lock. Studies of its use as a catheter lock in chronic hemodialysis patients suggest it may be efficacious in preventing infection and thrombotic complications. We compared sodium citrate with saline catheter locks for non-tunneled hemodialysis central venous catheters in critically ill adult patients. Primary endpoint was catheter life span without complication.

Methods

This was a randomized, controlled, open-label trial involving intensive care patients with acute renal failure requiring hemodialysis. Events were defined as catheter-related bloodstream infection and catheter malfunction.

Results

Seventy-eight patients were included. Median catheter life span without complication was 6 days (saline group) versus 12 days (citrate group) [hazard ratio (HR) 2.12 (95% CI 1.32–3.4), p = 0.0019]. There was a significantly higher rate of catheter malfunction in the saline group compared with in the citrate group (127 catheter events/1,000 catheter-days, saline group vs. 26 events/1,000 catheter-days, citrate group, p < 0.00001). There was no significant difference in incidence of infections between groups. We observed a significantly longer time to occurrence of infection in the citrate group (20 days vs. 14 days, HR 2.8, 95% CI 1.04–7.6, p = 0.04). By multivariate analysis, age and citrate group were the only independent factors that influenced catheter life span.

Conclusions

This study shows for the first time that citrate lock reduced catheter complications and increased catheter life span as compared to saline lock in critically ill adults requiring hemodialysis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Agee KR, Balk RA (1992) Central venous catheterization in the critically ill patient. Crit Care Clin 8:677–686

    PubMed  CAS  Google Scholar 

  2. Canaud B, Leray-Moragues H, Leblanc M, Klouche K, Vela C, Beraud JJ (1998) Temporary vascular access for extracorporeal renal replacement therapies in acute renal failure patients. Kidney Int Suppl 66:S142–S150

    PubMed  CAS  Google Scholar 

  3. Robert R, Honoré PM, Bastien O (2006) Les circulations extracorporelles en réanimation. Elsevier, Paris

    Google Scholar 

  4. Allon M (2003) Prophylaxis against dialysis catheter-related bacteremia with a novel antimicrobial lock solution. Clin Infect Dis 36:1539–1544. doi:10.1086/375234

    Article  PubMed  Google Scholar 

  5. Hendrickx L, Kuypers D, Evenepoel P, Maes B, Messiaen T, Vanrenterghem Y (2001) A comparative prospective study on the use of low concentrate citrate lock versus heparin lock in permanent dialysis catheters. Int J Artif Organs 24:208–211

    PubMed  CAS  Google Scholar 

  6. Vercaigne LM, Sitar DS, Penner SB, Bernstein K, Wang GQ, Burczynski FJ (2000) Antibiotic-heparin lock: in vitro antibiotic stability combined with heparin in a central venous catheter. Pharmacotherapy 20:394–399

    Article  PubMed  CAS  Google Scholar 

  7. Bailey E, Berry N, Cheesbrough JS (2002) Antimicrobial lock therapy for catheter-related bacteraemia among patients on maintenance haemodialysis. J Antimicrob Chemother 50:615–617

    Article  PubMed  CAS  Google Scholar 

  8. Poole CV, Carlton D, Bimbo L, Allon M (2004) Treatment of catheter-related bacteraemia with an antibiotic lock protocol: effect of bacterial pathogen. Nephrol Dial Transplant 19:1237–1244. doi:10.1093/ndt/gfh041

    Article  PubMed  CAS  Google Scholar 

  9. Grudzinski L, Quinan P, Kwok S, Pierratos A (2007) Sodium citrate 4% locking solution for central venous dialysis catheters–an effective, more cost-efficient alternative to heparin. Nephrol Dial Transplant 22:471–476. doi:10.1093/ndt/gfl606

    Article  PubMed  CAS  Google Scholar 

  10. Lok CE, Appleton D, Bhola C, Khoo B, Richardson RM (2007) Trisodium citrate 4%—an alternative to heparin capping of haemodialysis catheters. Nephrol Dial Transplant 22:477–483. doi:10.1093/ndt/gfl570

    Article  PubMed  CAS  Google Scholar 

  11. Weijmer MC, Debets-Ossenkopp YJ, Van De Vondervoort FJ, ter Wee PM (2002) Superior antimicrobial activity of trisodium citrate over heparin for catheter locking. Nephrol Dial Transplant 17:2189–2195

    Article  PubMed  CAS  Google Scholar 

  12. Weijmer MC, van den Dorpel MA, Van de Ven PJ, ter Wee PM, van Geelen JA, Groeneveld JO, van Jaarsveld BC, Koopmans MG, le Poole CY, Schrander-Van der Meer AM, Siegert CE, Stas KJ (2005) Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol 16:2769–2777. doi:10.1681/ASN.2004100870

    Article  PubMed  CAS  Google Scholar 

  13. Ash SR, Mankus RA, Sutton JM, Criswell RE, Crull CC, Velasquez KA, Smeltzer BD, Ing TS (2000) Concentrated sodium citrate (23%) for catheter lock. Hemodial Int 4:22–31

    Google Scholar 

  14. Hemmelgarn BR, Moist LM, Lok CE, Tonelli M, Manns BJ, Holden RM, LeBlanc M, Faris P, Barre P, Zhang J, Scott-Douglas N (2011) Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator. N Engl J Med 364:303–312. doi:10.1056/NEJMoa1011376

    Article  PubMed  CAS  Google Scholar 

  15. Allon M (2007) Current management of vascular access. Clin J Am Soc Nephrol 2:786–800. doi:10.2215/CJN.00860207

    Article  PubMed  Google Scholar 

  16. Yahav D, Rozen-Zvi B, Gafter-Gvili A, Leibovici L, Gafter U, Paul M (2008) 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 47:83–93. doi:10.1086/588667

    Article  PubMed  Google Scholar 

  17. Yevzlin AS, Sanchez RJ, Hiatt JG, Washington MH, Wakeen M, Hofmann RM, Becker YT (2007) Concentrated heparin lock is associated with major bleeding complications after tunneled hemodialysis catheter placement. Semin Dial 20:351–354. doi:10.1111/j.1525-139X.2007.00294.x

    Article  PubMed  Google Scholar 

  18. Selleng K, Warkentin TE, Greinacher A (2007) Heparin-induced thrombocytopenia in intensive care patients. Crit Care Med 35:1165–1176. doi:10.1097/01.CCM.0000259538.02375.A5

    Article  PubMed  CAS  Google Scholar 

  19. Priziola JL, Smythe MA, Dager WE (2010) Drug-induced thrombocytopenia in critically ill patients. Crit Care Med 38:S145–S154. doi:10.1097/CCM.0b013e3181de0b88

    Article  PubMed  Google Scholar 

  20. Strauss R, Wehler M, Mehler K, Kreutzer D, Koebnick C, Hahn EG (2002) Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome. Crit Care Med 30:1765–1771

    Article  PubMed  Google Scholar 

  21. Kellum JA, Mehta RL, Angus DC, Palevsky P, Ronco C (2002) The first international consensus conference on continuous renal replacement therapy. Kidney Int 62:1855–1863. doi:10.1046/j.1523-1755.2002.00613.x

    Article  PubMed  Google Scholar 

  22. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad, II, Randolph AG, Rupp ME, Saint S (2011) Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 39:S1–34. doi:10.1016/j.ajic.2011.01.003

    Google Scholar 

  23. McGee DC, Gould MK (2003) Preventing complications of central venous catheterization. N Engl J Med 348:1123–1133. doi:10.1056/NEJMra011883

    Article  PubMed  Google Scholar 

  24. Allon M (2004) Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis 44:779–791

    PubMed  Google Scholar 

  25. Le Gall JR, Neumann A, Hemery F, Bleriot JP, Fulgencio JP, Garrigues B, Gouzes C, Lepage E, Moine P, Villers D (2005) Mortality prediction using SAPS II: an update for French intensive care units. Crit Care 9:R645–R652. doi:10.1186/cc3821

    Article  PubMed  Google Scholar 

  26. Fleming TR (1982) One-sample multiple testing procedure for phase II clinical trials. Biometrics 38:143–151

    Article  PubMed  CAS  Google Scholar 

  27. Maki DG, Ash SR, Winger RK, Lavin P (2011) A novel antimicrobial and antithrombotic lock solution for hemodialysis catheters: a multi-center, controlled, randomized trial. Crit Care Med 39:613–620. doi:10.1097/CCM.0b013e318206b5a2

    Article  PubMed  CAS  Google Scholar 

  28. Timsit JF, Bruneel F, Cheval C, Mamzer MF, Garrouste-Orgeas M, Wolff M, Misset B, Chevret S, Regnier B, Carlet J (1999) Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial. Ann Intern Med 130:729–735

    PubMed  CAS  Google Scholar 

  29. Parienti JJ, Thirion M, Megarbane B, Souweine B, Ouchikhe A, Polito A, Forel JM, Marque S, Misset B, Airapetian N, Daurel C, Mira JP, Ramakers M, du Cheyron D, Le Coutour X, Daubin C, Charbonneau P (2008) Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 299:2413–2422. doi:10.1001/jama.299.20.2413

    Article  PubMed  CAS  Google Scholar 

  30. Parienti JJ, Megarbane B, Fischer MO, Lautrette A, Gazui N, Marin N, Hanouz JL, Ramakers M, Daubin C, Mira JP, Charbonneau P, du Cheyron D (2010) Catheter dysfunction and dialysis performance according to vascular access among 736 critically ill adults requiring renal replacement therapy: a randomized controlled study. Crit Care Med 38:1118–1125. doi:10.1097/CCM.0b013e3181d454b3

    Article  PubMed  Google Scholar 

  31. Uhl L, Maillet S, King S, Kruskall MS (1997) Unexpected citrate toxicity and severe hypocalcemia during apheresis. Transfusion 37:1063–1065

    Article  PubMed  CAS  Google Scholar 

  32. Power A, Duncan N, Singh SK, Brown W, Dalby E, Edwards C, Lynch K, Prout V, Cairns T, Griffith M, McLean A, Palmer A, Taube D (2009) Sodium citrate versus heparin catheter locks for cuffed central venous catheters: a single-center randomized controlled trial. Am J Kidney Dis 53:1034–1041. doi:10.1053/j.ajkd.2009.01.259

    Article  PubMed  CAS  Google Scholar 

  33. Dogra GK, Herson H, Hutchison B, Irish AB, Heath CH, Golledge C, Luxton G, Moody H (2002) Prevention of tunneled hemodialysis catheter-related infections using catheter-restricted filling with gentamicin and citrate: a randomized controlled study. J Am Soc Nephrol 13:2133–2139

    Article  PubMed  CAS  Google Scholar 

  34. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM (2004) Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32:2014–2020

    Article  PubMed  Google Scholar 

  35. Warren DK, Zack JE, Mayfield JL, Chen A, Prentice D, Fraser VJ, Kollef MH (2004) The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest 126:1612–1618. doi:10.1378/chest.126.5.1612

    Article  PubMed  Google Scholar 

  36. Kaplowitz LG, Comstock JA, Landwehr DM, Dalton HP, Mayhall CG (1988) A prospective study of infections in hemodialysis patients: patient hygiene and other risk factors for infection. Infect Control Hosp Epidemiol 9:534–541

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We are grateful to the patients and their families and the nurses and physicians in the participating ICU for their support of this trial. We would also like to thank the clinical research division (DRCI) of the University Hospital of Dijon for their support. The authors thank Fiona Ecarnot for translation and editorial assistance. This work was financed by the University Hospital of Dijon Clinical Research Division.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. CHU de Dijon, Hôpital du Bocage, Réanimation Traumatologique et Neurochirurgicale, Université de Bourgogne, Dijon, France

    Laure Hermite, Abdelouaid Nadji & Marc Freysz

  2. CHU de Dijon, Hôpital du Bocage, Réanimation Médicale, Université de Bourgogne, 14 rue Paul Gaffarel, BP 77908, 21079, Dijon cedex, France

    Jean-Pierre Quenot, Saber David Barbar, Pierre-Emmanuel Charles, Maël Hamet & Nicolas Jacquiot

  3. INSERM 866, Centre Georges-François Leclerc, Université de Bourgogne, Dijon, France

    François Ghiringhelli

Authors
  1. Laure Hermite
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jean-Pierre Quenot
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Abdelouaid Nadji
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Saber David Barbar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Pierre-Emmanuel Charles
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Maël Hamet
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Nicolas Jacquiot
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. François Ghiringhelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Marc Freysz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jean-Pierre Quenot.

Additional information

L. Hermite, J.-P. Quenot, A. Nadji, and S. D. Barbar contributed equally to the work.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hermite, L., Quenot, JP., Nadji, A. et al. Sodium citrate versus saline catheter locks for non-tunneled hemodialysis central venous catheters in critically ill adults: a randomized controlled trial. Intensive Care Med 38, 279–285 (2012). https://doi.org/10.1007/s00134-011-2422-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-011-2422-y

Keywords

Search

Navigation