Non-tunneled versus tunneled dialysis catheters for acute kidney injury requiring renal replacement therapy: a prospective cohort study

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Abstract

Background

Acute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high morbidity, mortality and resource utilization. The type of vascular access placed for AKI-RRT is an important decision, for which there is a lack of evidence-based guidelines.

Methods

We conducted a prospective cohort study over a 16-month period with 154 patients initiated on AKI-RRT via either a non-tunneled dialysis catheter (NTDC) or a tunneled dialysis catheter (TDC) at an academic hospital. We compared differences in renal replacement delivery and mechanical and infectious outcomes between NTDCs and TDCs.

Results

Patients who received TDCs had significantly better RRT delivery, both with continuous venovenous hemofiltration (CVVH) and intermittent hemodialysis (IHD), compared to patients who received NTDCs; these findings were confirmed after multivariable adjustment for AKI-specific disease severity score, history of chronic kidney disease, renal consult team, and AKI cause. In CVVH and IHD, the median venous and arterial blood flow pressures were significantly higher with TDCs compared to NTDCs ( p < 0.001). Additionally for CVVH, the median number of interruptions per catheter was higher with NTDCs compared to TDCs (Rate Ratio (RR) 2.7; p < 0.001), and for IHD, a higher median blood flow was seen with TDCs ( p < 0.001). There were a significantly higher number of mechanical complications with NTDCs (RR 13.6 p = 0.001). No significant difference was observed between TDCs and NTDCs for positive blood cultures per catheter.

Conclusions

Compared to NTDCs, TDCs for patients with AKI-RRT had improved RRT delivery and fewer mechanical complications. Initial TDC placement for AKI-RRT should be considered when not clinically contraindicated given the potential for improved RRT delivery and outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12882-017-0760-x) contains supplementary material, which is available to authorized users.

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Most cited references 11

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Acute kidney injury, mortality, length of stay, and costs in hospitalized patients.

Glenn Chertow, Elisabeth Burdick, Melissa M Honour … (2005)

The marginal effects of acute kidney injury on in-hospital mortality, length of stay (LOS), and costs have not been well described. A consecutive sample of 19,982 adults who were admitted to an urban academic medical center, including 9210 who had two or more serum creatinine (SCr) determinations, was evaluated. The presence and degree of acute kidney injury were assessed using absolute and relative increases from baseline to peak SCr concentration during hospitalization. Large increases in SCr concentration were relatively rare (e.g., >or=2.0 mg/dl in 105 [1%] patients), whereas more modest increases in SCr were common (e.g., >or=0.5 mg/dl in 1237 [13%] patients). Modest changes in SCr were significantly associated with mortality, LOS, and costs, even after adjustment for age, gender, admission International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, severity of illness (diagnosis-related group weight), and chronic kidney disease. For example, an increase in SCr >or=0.5 mg/dl was associated with a 6.5-fold (95% confidence interval 5.0 to 8.5) increase in the odds of death, a 3.5-d increase in LOS, and nearly 7500 dollars in excess hospital costs. Acute kidney injury is associated with significantly increased mortality, LOS, and costs across a broad spectrum of conditions. Moreover, outcomes are related directly to the severity of acute kidney injury, whether characterized by nominal or percentage changes in serum creatinine.

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Model to predict mortality in critically ill adults with acute kidney injury.

Sevag Demirjian, Paul Palevsky, Theresa O'Connor … (2011)

Acute kidney injury (AKI) requiring dialysis is associated with high mortality. Most prognostic tools used to describe case complexity and to project patient outcome lack predictive accuracy when applied in patients with AKI. In this study, we developed an AKI-specific predictive model for 60-day mortality and compared the model to the performance of two generic (Sequential Organ Failure Assessment [SOFA] and Acute Physiology and Chronic Health Evaluation II [APACHE II]) scores, and a disease specific (Cleveland Clinic [CCF]) score. Data from 1122 subjects enrolled in the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network study; a multicenter randomized trial of intensive versus less intensive renal support in critically ill patients with AKI conducted between November 2003 and July 2007 at 27 VA- and university-affiliated centers. The 60-day mortality was 53%. Twenty-one independent predictors of 60-day mortality were identified. The logistic regression model exhibited good discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.85 (0.83 to 0.88), and a derived integer risk score yielded a value of 0.80 (0.77 to 0.83). Existing scoring systems, including APACHE II, SOFA, and CCF, when applied to our cohort, showed relatively poor discrimination, reflected by areas under the ROC curve of 0.68 (0.64 to 0.71), 0.69 (0.66 to 0.73), and 0.65 (0.62 to 0.69), respectively. Our new risk model outperformed existing generic and disease-specific scoring systems in predicting 60-day mortality in critically ill patients with AKI. The current model requires external validation before it can be applied to other patient populations.

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Author and article information

Contributors

Mallika L. Mendu: 203.809.9190 , mmendu@partners.org

Journal

Journal ID (nlm-ta): BMC Nephrol

Journal ID (iso-abbrev): BMC Nephrol

Title: BMC Nephrology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2369

Publication date (Electronic): 4 December 2017

Publication date PMC-release: 4 December 2017

Publication date Collection: 2017

Volume: 18

Electronic Location Identifier: 351

Affiliations

[1 ]Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA

[2 ]ISNI 0000 0004 0378 8438, GRID grid.2515.3, Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, ; Boston, MA USA

[3 ]ISNI 0000 0004 0382 382X, GRID grid.416843.c, Internal Medicine Residency Program, , Mount Auburn Hospital, ; Cambridge, MA USA

[4 ]Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA

[5 ]ISNI 0000 0004 0378 8294, GRID grid.62560.37, One Brigham Circle, , Brigham and Women’s Hospital, ; Boston, MA 02115 USA

Article

Publisher ID: 760

DOI: 10.1186/s12882-017-0760-x

PMC ID: 5715550

PubMed ID: 29202728

SO-VID: 247ab1cc-5501-4aef-9e8c-e3005ef538d3

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 16 August 2017

Date accepted : 16 November 2017

Custom metadata

ScienceOpen disciplines: Nephrology

Keywords: acute kidney injury (aki),renal replacement therapy (rrt),non-tunneled dialysis catheter (ntdc),tunneled dialysis catheter (tdc),continuous venovenous hemofiltration (cvvh),intermittent hemodialysis (ihd)

Data availability:

ScienceOpen disciplines: Nephrology

Keywords: acute kidney injury (aki), renal replacement therapy (rrt), non-tunneled dialysis catheter (ntdc), tunneled dialysis catheter (tdc), continuous venovenous hemofiltration (cvvh), intermittent hemodialysis (ihd)

Non-tunneled versus tunneled dialysis catheters for acute kidney injury requiring renal replacement therapy: a prospective cohort study

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Abstract

Background

Methods

Results

Conclusions

Electronic supplementary material

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Karger: Nephrology

Most cited references 11

Acute kidney injury, mortality, length of stay, and costs in hospitalized patients.

Intravascular-catheter-related infections.

Model to predict mortality in critically ill adults with acute kidney injury.

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