Original Investigation
Dialysis
A Randomized Trial of Catheters of Different Lengths to Achieve Right Atrium Versus Superior Vena Cava Placement for Continuous Renal Replacement Therapy

https://doi.org/10.1053/j.ajkd.2012.01.021Get rights and content

Background

The aim was to assess whether inserting a longer soft silicone short-term dialysis catheter targeting tip placement in the right atrium could improve dialyzer circuit life span compared with inserting a shorter dialysis catheter targeting tip placement in the superior vena cava.

Study Design

Randomized unblinded controlled study.

Setting & Participants

A tertiary multidisciplinary intensive care unit enrolling 100 critically ill patients requiring continuous renal replacement therapy (CRRT).

Intervention

Placement of longer (20-24 cm) versus shorter dialysis catheters (15-20 cm) within one of the major thoracic veins for initiation of CRRT.

Outcomes

The primary study outcome was duration of dialysis circuit life span. Secondary outcomes included delivered daily dialysis dose, incidence and cause of CRRT circuit failure, complications potentially related to the position of the short-term dialysis catheter, mortality, and patient length of stay.

Results

Placing the longer dialysis catheters was associated with an increased average dialyzer life span of 6.5 hours (24 hours [25th-75th percentile, 11-32] vs 17.5 hours [25th-75th percentile, 8-23]; P = 0.001), improved delivered daily dialysis dose (91% [25th-75th percentile, 85%-100%] vs 81% [25th-75th percentile, 72%-97%]; P < 0.001), and reduced number of dialyzers clotted (2.3 vs 3.6; P = 0.04) or circuits taken down due to vascular access problem (0.19 vs 0.53; P = 0.04) per patient compared with placing shorter dialysis catheters. The incidence of atrial arrhythmias was similar between groups (28% vs 21%; P = 0.6) and the only mechanical complication was the malposition of one dialysis catheter tip in the longer dialysis catheter group.

Limitations

Single-center study design.

Conclusions

The use of longer soft silicone short-term dialysis catheters targeting right atrial placement appeared to be safe and could improve dialyzer life span and daily dialysis dose of CRRT delivered compared with the use of shorter catheters targeting superior vena cava placement.

Section snippets

Study Design

This was a single-center, unblinded, randomized, controlled trial with parallel-group design and 1:1 allocation ratio.

Setting & Participants

This study was conducted in a 31-bed multidisciplinary intensive care unit (ICU) in which CRRT is the only form of acute dialysis used. After obtaining Hospital Ethics Committee approval, this study was granted a waiver for patients unable to provide written consent at the time of enrolment. An interim analysis of safety data after the first 40 participants was presented to our

Recruitment

Of 100 patients eligible and enrolled in the study between February 2010 and February 2011, a total of 50 patients was randomly assigned to each of the 2 short-term dialysis catheter groups (shorter vs longer catheters). Six patients could not complete the study (Fig 2), but 5 of these patients who were randomly assigned still had a catheter inserted and were followed up for any possible complications attributable to their catheter position per intention-to-treat analysis.

Baseline Characteristics

Baseline

Discussion

The optimal position for the tip of a dialysis catheter in the delivery of renal replacement therapy remains uncertain and controversial. The Society of Interventional Radiology Technology Assessment Committee in 2003 published the “Reporting Standards for Central Venous Access,” suggesting that the best location for the CVC tip has not yet been determined.7 The National Kidney Foundation KDOQI (Kidney Disease Outcomes Quality Initiative) 2006 guidelines stated that short-term dialysis catheter

Acknowledgements

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

References (16)

There are more references available in the full text version of this article.

Cited by (62)

  • Deeper may not be better: relationship between catheter dysfunction and location of the catheter tip in right-sided tunnelled haemodialysis catheters

    2022, Clinical Radiology
    Citation Excerpt :

    Another hypothesis on how CVC tip location relates to catheter dysfunction suggests that contact between the catheter tip and the SVC or atrial wall negatively impacts fluid dynamics and promotes fibrin sheath formation.26 This has led some authors to recommend placing the CVC tip in the right atrium due to the theoretical possibility of the SVC wall collapsing against the catheter during haemodialysis.27 Based on the results of the present study, the higher occurrence of catheter dysfunction amongst step-tip CVCs ending deep in the right atrium may similarly be related to abutment against the atrial wall.

  • Management of Acute Kidney Injury in Coronavirus Disease 2019

    2020, Advances in Chronic Kidney Disease
    Citation Excerpt :

    The femoral vein site may be associated with higher risk for infections and blood flows may be affected in patients who need to be proned for ventilation. The left IJ can provide inadequate blood flow, especially when shorter catheters are inadvertently placed.33 In the setting of a surge, physicians not familiar with hemodialysis catheters may be responsible for placing catheters in patients with COVID-19.

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Originally published online on April 13, 2012.

Trial registration: www.ANZCTR.org.au; study number: ACTRN12611000759998.

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