A randomized controlled clinical trial of 4% sodium citrate versus heparin as locking solution for temporary dialysis catheters among hemodialysis patients

Abstract

Catheters are frequently used as means of vascular access in patients who require both temporary and long-term hemodialysis (HD) and who have a non-functional arteriovenous fistula (AVF) or graft (AVG) (Canadian Institute for Health Information, 2007). However, catheter use is associated with several issues including frequent thrombosis and infections. Consequently, patients who are dependant on catheters require more hospitalizations, have to incur higher costs, and are at an increased risk of inadequate dialysis and higher morbidity and mortality (Allon, 2003). Maintenance of catheter patency is critical for such patients. Heparin has been used as the standard prophylactic regimen for locking catheters as to prevent thrombosis and subsequent catheter dysfunction (Astor et al., 2005). However, the complications of using heparin include local and systemic bleeding events and its potential for inducing thrombocytopenia (National Kidney Foundation, 2006). To date, there are no clear guidelines on optimal catheter locking solution (Jindal et al., 2006). Therefore, it is recommended that some form of catheter lock solution must be employed; however, randomized control trials and further data are required to determine the optimal solution (Mendelssohn et al., 2006). Recently, there has been an increasing demand for citrate as an alternate to heparin for use as a locking solution for HD catheters, owing to its antithrombotic and antimicrobial properties. Furthermore, citrate may also be a safer alternative to heparin with regards to risks of bleeding (Betjes and Agteren, 2004). On the other hand, about 20% of prevalent and 80% of incident HD patients in the United States use tunneled cuffed catheters (TCC), and this proportion is even higher in some other countries (Astor et al., 2005; National Kidney Foundation, 2006). Nonetheless, the use of TCCs is limited in Egypt owing to the higher cost and lack of expertise required for the insertion technique, particularly among the practicing nephrologists (with high dependency on Utilization Certificates [UCs]). The prevalence and types of vascular access in Egypt are poorly investigated with only a limited number of reports available.