Outcomes of tunneled internal jugular venous catheters for chronic haemodialysis at the University College Hospital, Ibadan, Nigeria

Introduction vascular access is an important aspect of haemodialysis treatments and determinant of patient outcomes. Arteriovenous (AV) fistula has been described as the preferred haemodialysis vascular access for patients on chronic dialysis. There continues to be a challenge with the creation of AV fistula, due to shortage of vascular surgeons skilled in the AV fistula creation particularly in source limited setting. We described the outcomes of the tunneled internal jugular venous catheters amongst our patients at the University College Hospital (UCH) Ibadan. Methods a retrospective study of patients on maintenance haemodialysis at the UCH, Ibadan, we reviewed the records of all patients on chronic dialysis over a period of 5 years. Information obtained include demographics, types and aetiology of renal failure, types of vascular access, observed complications and outcomes. Results a total number of 147 catheters were inserted during the period under review, 94 were males while 53 were females. The age range was 18-85 years while the mean age was 46.3 ± 17.2 years. The range and mean duration for Tunneled Dialysis Catheter (TDC) carriage were (30 - 1,440) and 220±185 days respectively. The observed immediate complications of TDCs were failed first attempt 7(4.7%), reactionary haemorrhage 5(3.4%), arrhythmia 3(2.0%), haemothorax 2(1.4%) while death during catheter placement was recorded in 2(1.4%) cases. Catheter related infection was the commonest long-term complications and occurred in 15 cases (10.1%), while being diabetic increased the risk of developing catheter related complications. One tenth of our patients with End Stage Renal Disease on TDC had kidney transplantation while catheter related mortality was 16.3%. Conclusion internal jugular tunneled dialysis catheters despite its shortcomings, has been a safe procedure with good outcomes among our patients on maintenance haemodialysis.


Introduction
Vascular access is an important aspect of haemodialysis treatment and arteriovenous (AV) fistula has been described as the most preferred haemodialyis access type for patients on chronic dialysis [1]. In addition, haemodialysis vascular access is a major determinant of outcomes among patients on maintenance haemodialysis [2,3]. Over the last decade the National Kidney Foundation-Kidney Disease Outcome Quality initiatives (NKF-KDOQI) through the fistula first initiatives has spearheaded the campaign for initiating maintenance haemodialysis with AV fistula [4,5]. The campaign is based on the several advantages of AV fistula over other forms of haemodialysis vascular access [6]. The benefits of AV fistula include low rate of bacteremia, thrombosis, stenosis and reduction in overall morbidity and mortality [3,7]. Despite the success of the fistula first movement in ensuring that most patients with end stage renal disease (ESRD) commence haemodialysis with AV fistula, the use of Tunneled Dialysis Catheters (TDCs) is still on the rise worldwide [8,9]. The use of dialysis catheters is often discouraged because of the various complications associated with its use, such complications include catheter related infections, thrombosis, subclavian or jugular vein stenosis, inadequate dialysis and poor quality of life [10,11]. Furthermore, all-cause mortality is higher among End Stage Renal Disease (ESRD) patients dialyzing with dialysis catheter compared to patients undergoing dialysis with AV fistula [12]. Even with its many challenges, the use of TDCs is particularly common in the low and medium income countries (LMICs), where vascular surgeons skilled in AV fistula creation were not readily available and patients often present late [

Methods
This is a retrospective study of ESRD patients on maintenance haemodialysis at the University College Hospital, Ibadan, Nigeria. We reviewed the dialysis records of all patients on chronic dialysis over a period of 5 years (January 2013-December 2017). Information obtained include demographics, types and aetiology of renal failure, types of vascular access, number of attempts at creating the vascular access, observed complications and outcomes. Maintenance haemodialysis was defined as regular intermittent haemodialysis offered to patients with ESRD [18]. All patients on maintenance dialysis with tunneled curved internal jugular catheter were observed for immediate and long term complications associated with the catheter use. The protocol used by our unit is as highlighted below.

Procedure protocol
Obtaining informed consent: informed consent was obtained from all patients prior to the procedure and after explaining the procedure, why it is needed, possible complication that may arise from it and the post-catheter care required.   (Table 3).

Discussion
Our study showed that TDC is increasingly being used as vascular access for maintenance haemodialysis in our hospital and one third of patients on TDC developed catheter related complications. The commonest immediate complication observed was failure of first attempt at passing the catheter, while catheter related infection was the leading long-term complications observed. There was a high rate of TDC use among our patients with ESRD, mainly for its convenience and ease of use and more importantly because its insertion can be carried out by the nephrologists, unlike the AV fistula creation that requires experienced vascular surgeons, whom were in short supply in most hospitals in Nigeria. Secondly, patients often present late in the hospital with advanced kidney disease [16,19], such that most require immediate maintenance haemodialysis. This pattern of vascular access used for haemodialysis in our study is similar to what obtains in other LMICs, where vascular surgeons skilled in skills in AV fistula creation are not available [8,20]. The increasingly important role of TDC for the delivery of haemodialysis in resource limited settings as against the use of AV fistula or graft is of great concern and could be a contributing factor to the poor quality of life and suboptimal patients' outcomes. In one report on haemodialysis vascular access use from Uyo, South South Nigeria by Ekpe et al. [21], only 5% of their patients with ESRD dialyzed with permanent vascular access. Failed first attempt at catheter insertion was the commonest immediate complication observed among our patients, this is not surprising as the procedure was carried out without ultrasonographic guidance, due to lack of ultrasound scan machine in our dialysis centre at the time and non-availability of dedicated ultrasound machine for the procedure at the radiology department. The ultrasound assisted catheter insertion has been shown to reduce the rate of failed first attempts at catheter placement and other immediate complications commonly associated with blind insertion and has become standard of care [20,22]. Two of our patients with antibiotics has been shown to reduce the incidence of catheter related infection, particularly bacteremia [28], suggesting that the incidence of catheter related infections would have been higher in our patients, if not for the use of antibiotic catheter lock or perhaps the antibiotic use was inappropriate [29]. The high rate of catheter related infection in our patients was similar to those reported in other forms of indwelling catheter use in our setting. Ademola et al. [30] reported peritonitis in 10 out 27 children who had peritoneal dialysis using improvised catheter in Ibadan while Komolafe et al. [31] observed catheter related infection rate of 19.4% in children who had ventriculoperitoneal shunts for treatments of hydrocephalus in Ile-Ife.
Only 10% of our ESRD patients who were on TDC for haemodialysis had their catheter removed because they had kidney transplantation. This is because only few of our patients could afford kidney transplantation as a modality of treatment, as patients pay out of pockets for their renal care in Nigeria [32]. The inclusion of renal care services in the current National Health Insurance Scheme (NHIS) will go a long way in ensuring more patients transit from TDC based haemodialysis to kidney transplantation. We observed that ESRD patients with diabetes mellitus were more likely to develop catheter related complications and this agrees with previous reports on TDC use. Uncontrolled diabetes mellitus increases the risk of infection, thrombosis and catheter failure [33,34]. This is because hyperglycaemia provides a good medium for bacteria growth, in addition to immunosuppression and vascular disease commonly encountered in patients with uncontrolled diabetes mellitus. The catheter related mortality of 16.3% observed in this cohort was high, however, the high mortality might have also been contributed to by other factors. Other factors contributing to the poor patient outcomes were inadequate haemodialysis, sub-optimal anaemia treatment, cardiovascular mortality, malnutrition and high incidence of infection.
Despite the low rate of complications in the use of TDC, its use should be restricted to when the ideal is not available, particularly in the setting where the technical know-how for AV fistula creation is not readily available. However, the use of TDC in resource challenge setting should be embarked upon with adequate precautions geared towards reducing the high rate of complications. These steps should include appropriately selecting suitable patients for the procedure, use of ultrasonography and fluoroscopy, cardiac monitoring during and immediately after the procedure, while adequate catheter care during and in-between dialysis must be ensured. While TDC is being used as a temporary vascular access, efforts should be made to train vascular surgeons in creation of AV fistula in source challenged country like Nigeria. This study is not without limitations, some patients with TDC were lost to follow up, such that the patients' and catheter outcomes could not be ascertained in them. Also, the contributions of other factors such as inadequate anaemia treatment and haemodialysis could not be excluded in the patients with catheter related mortalities.

Conclusion
Internal jugular tunneled dialysis catheters despite its shortcomings, has been a safe procedure with good outcomes among patients on