Sodium Citrate Versus Heparin Catheter Locks for Cuffed Central Venous Catheters: A Single-Center Randomized Controlled Trial
Received 20 August 2008; accepted 13 January 2009. published online 27 April 2009.
Background
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 have suggested its efficacy in preventing infection and bleeding complications compared with sodium heparin.
Study Design
Open-label randomized controlled trial of 2 catheter locks to examine the hypothesis that sodium citrate catheter locks will reduce catheter-related bacteremia and exit-site infection.
Settings & Participants
232 consenting long-term hemodialysis patients in 4 satellite dialysis units to a large dialysis program with protocolized treatment and targets. All patients were using twin-catheter single-lumen Tesio-Caths (MedComp, Harleysville, PA).
Intervention
6 months' use of 46.7% sodium citrate (citrate) or 5% heparin (heparin) locked postdialysis in the dead space of the central venous catheter.
Outcomes & Measurements
Primary end point of catheter-related bacteremia and exit-site infection. Secondary end points of catheter thrombosis defined by the use of urokinase lock and infusion, new catheter insertion, catheter-related admission, blood transfusions, parenteral iron, and erythropoietin requirements.
Results
Catheter-related bacteremia did not differ in the 2 groups, with an incidence of 0.7 events/1,000 catheter-days. There was no significant difference in rates of exit-site infection (0.7 versus 0.5 events/1,000 catheter-days; P = 0.5). The secondary end point of catheter thrombosis defined by the use of a urokinase lock was significantly more common in the citrate group, with an incidence of 8 versus 4.3/1,000 catheter-days (P < 0.001). Other secondary end points did not differ. Citrate treatment was curtailed compared with heparin because of a greater incidence of adverse events, with a mean treatment duration before withdrawal of 4.8 ± 2.0 versus 5.7 ± 1.2 months, respectively (P < 0.001).
Limitations
Low baseline catheter-related bacteremia and exit-site infection event rates may have underpowered this study. High adverse-event rates may have been related to high-concentration citrate that led to increased overspill and reduction in lock volume. This may also explain the increased rates of thrombosis in this group.
Conclusion
Widespread and long-term use of 46.7% citrate catheter locks with Tesio-Cath access is not justified by this study.
Haemodialysis Research Group, Imperial College Kidney and Transplant Institute, West London Renal and Transplant Centre, Hammersmith Hospital, London, UK
Address correspondence to Albert Power, MBBChir, MRCP, West London Renal and Transplant Centre, Hammersmith Hospital, DuCane Rd, London W12 0HS, United Kingdom
ABSTRACT