Download [1,2]. Therefore, right atrial electroc

912
Letters
malposition of a catheter represent acute complications of
central venous access devices [1,2]. Therefore, right atrial
electrocardiography was introduced by Wilson and Gaer for
proper placement of central venous lines [3]. Recently,
Dionisio et al. and Galli et al. reported on the applicability
of this technique for safe placement of haemodialysis catheters [4,5]. In order to find out whether overinsertion of
guide wires (advancing the guide wire into the right heart to
provoke dysrhythmia) is a safe procedure to assure correct
catheter placement, guide-wire-associated complications of
percutaneous insertion of central venous catheters were
evaluated at the acute dialysis unit of the University Hospital
of Vienna.
The insertion of 1527 central venous catheters was evaluated with respect to malposition and symptomatic arrhythmia
during an observation period of 3 years. Double-lumen
dialysis catheters, Dacron-cuffed permanent dialysis catheters, Hickman catheters, implantable port systems, and
infusion catheters were implanted for the care of renal failure
and cancer patients. Catheters were placed by staff and
rotating physicians using Seldinger's technique and transthoracal electrocardiogram monitoring. Application of
fiuoroscopic technique or ultrasound guided puncture was
limited to patients with venous stenosis or thrombosis due
to previous catheters. Following venous puncture the
guidewire was over-inserted into the right heart, indicating
proper placement along the superior vena cava. Once Interferon-alpha treatment of haemodialysis patients
dysrhythmia was registered, the guidewire was relocated into with chronic viral hepatitis and its impact on kidney
the superior vena cava and the sheet and/or the catheter transplantation
(<20cm length) was introduced.
In our patients no haemodynamic relevant dysrhythmia Sir,
necessitating other therapeutic interventions than reposi- In a recent issue of a journal [1], there was an interesting
tioning of the guide wire (asymptomatic dysrhythmia was paper on interferon (INF)-alpha therapy in haemodialysis
seen in about 50% of our patients) was observed. In a recent patients with chronic viral hepatitis. It was stated in the
study atrial arrhythmias and ventricular ectopy occurred abstract that 'interferon-alpha has not been used previously
with a frequency of 41 and 25% respectively. Similar to our in haemodialysis patients with chronic hepatitis'. Therefore,
study, no malignant arrhythmia was observed [6]. This is in I am very pleased to give more information about INF
contrast to the data of McDowell et al. who described therapy on our haemodialysis patients with chronic
symptomatic ventricular tachycardia in 1% (2/200) of haemo- hepatitis C virus (HCV) infection [2].
Forty-five adult patients with chronic HCV infection who
dialysis patients [7] and Brothers et al. who described a
had elevated transaminases and histologically proven chronic
complication rate of 0.9% (3/329) in cancer patients [8].
Following puncture of the right subclavian vein eight hepatitis were treated with interferon-alpha (Roferon,
catheters were misplaced into the right jugular vein and seven Roche) 3 million units three times a week s.c. for 6 months.
catheters into the left subclavian vein. Two catheters were All patients had evidence of HCV infection with HCV RNA
misplaced into other vessels. Five catheters introduced via (polymerase chain reaction) and antibody to HCV in serum
the right jugular vein were all misplaced into the right (by second generation ELISA). Seventeen of the 45 patients
subclavian vein. Of two catheters inserted via the left jugular had chronic renal failure (CRF).
Fifteen of 17 haemodialysis patients with chronic HCV
vein, one was introduced into the right jugular vein and the
other, even though using fiuoroscopic technique, was repeat- infection (88%) and 14 patients of 28 patients without CRF
edly located in the left subclavian or the right jugular vein. (50%) had a complete biochemical response (normalization
One catheter inserted via the left subclavian vein was located of serum ALT levels) at the end of the 6th month of therapy.
in the left jugular vein. Thus the application of this technique The rate of complete response was higher in haemodialysis
resulted in a very low malposition rate of 1.64% (25/1527) patients compared those with normal renal function
compared to 4.2% (15/355) in other studies [9].
(/)<0.05). Five haemodialysis patients and eight patients
with
normal renal function showed histological improvement
We therefore conclude that overinsertion of guidewires,
monitored by transthoracic electrocardiography, represents in control liver biopsy after interferon therapy. The adminisa useful and safe technique to assure proper placement of tration of INF was not associated with any severe complicacentral venous access devices in chronic renal failure and tions. Five haemodialysis patients and seven patients without
chronic renal failure showed increase in serum ALT level at
cancer patients.
3 months after INF therapy.
KJinische Abteilung fur Nephrologie
G. SunderFour patients with CRF had renal transplantation after
und Dialyse, Universitatsklinik fur
Plassmann another 6 months follow up, with normal serum ALT levels.
Innere Medizin HI, Universitat Wien,
M. Muhm Three patients received kidneys from first-degree relatives
Wien, Austria
W. Drum and one from a cadaver. One patient underwent liver biopsy
6 months after kidney transplantation, and liver histology
1. Cobb DK, High KP, Sawyer RG et al. A controlled trial of
showed no differences compared to previous pre- and postscheduled replacement of central venous and pulmonary artery
treatment biopsies. The renal recipients were followed for
catheters. N Engl J Med 1992; 327: 1062-1068
2. Dunbar RD, Mitchell R, Lavine M. Aberrant locations of central
venous catheters. Lancet 1981; 711-715
3. Wilson RG, Gaer JAR. Right atrial electrocardiography in
placement of central venous catheters. Lancet 1988; 462-463
4. Dionisio P, Valenti M, Cornelia C et al. Monitoring of central
venous dual-lumen catheter placement in haemodialysis: improvement of a technique for the practising nephrologist. Nephrol Dial
Transplant 1995; 10: 874-876
5. Galli F, Efficace E, Villa G et al. Endocavitary electrocardiography (EC-ECG) in monitoring central venous cannulation for
vascular access in haemodialysis. Nephrol Dial Transplant 1993;
8: 480-481 (letter)
6. Stuart RK, Shikora SA, Akerman P el al. Incidence of arrhythmia
with central venous catheter insertion and exchange. JPEN 1990;
14: 152-155
7. McDowell DE, Moss AH, Vasilakis C, Bell R, Pillai L.
Percutaneously placed dual-lumen silicone catheters for long-term
hemodialysis. Am Surg 1993; 59: 568-573
8. Brothers TE, Von Moll LK, Niederhuber JE, Roberts JA, WalkerAndrews S, Ensminger WD. Experience with subcutaneous infusion ports in three hundred patients. Surg Gynecol Obstet 1988;
166: 295-301
9. Henriques HF, Karmy Jones R, Knoll SM, Copes WS, Giordano
JM. Avoiding complications of long term venous access. Am Surg
1993; 59: 555-558
Letters
913
these patients present as uraemic emergencies requiring dialysis within 24-48 h of admission and the other 50% have
failure of function of their dialysis access.
We would like to report our experience with a single lumen
silicone catheter with one cuff (Kimal UK, Limited). The
jugular route was chosen due to the lower rate of complications [2] associated with it.
All catheters were inserted percutaneously using the
Seldinger technique under fluoroscopy and sedation with
Midazolam. The catheter introducer was the peel away
sheath FG16 (Kimal UK, Limited). Forty-three catheters
were inserted in the right internal jugular veins and one in
the external jugular vein. There were 16 males and 17 females
aged between 32 and 81 years.
Complications were as follows:
1. Respiratory arrest occurred in one patient following
3 mg of intravenous Midazolam requiring endotracheal
intubation and ventilation, until the effect was reversed with
slow bolus injection of 300 meg Flumazenil.
2. One patient bled from the exit site and required exploration of trie catheter tunnel. An arterial bleeding point was
found and tied off and the catheter was retunnelled to
another point on the anterior chest wall.
3. Fourteen episodes of exit site infections occurred in nine
patients (27.2%), eight of these infections (57%) in four
patients with diabetes mellitus, patients with diabetes made
12% of the total study of population. Nine episodes were
due to Staphylococus aureus, two Staphylococcus epidermis,
one Proteus, and two were culture negative but due to
Department of Internal Medicine,
Halis Simsek production of purulent discharge these were considered as
Section of Gastroenterology,
exit site infections. All exit site infections were treated with
Hacettepe University Medical School,
a combination of Flucloxacillin and Rifampicin, the comAnkara,
bination of which has been successful in the treatment of
Turkey
exit site infections related to Tenckhoff catheters for continuous ambulatory peritoneal dialysis [5]. We eradicated all the
1. Duarte R, Huraib S, Said R et al. Interferon-alpha facilitates
infections except two. These two catheters were removed and
renal transplantation in hemodialysis patients with chronic viral
the infections eventually settled without recurrence.
hepatitis. Am J Kidney Dis 1995; 25: 40-45
2. Simsek H, Ozyilkan E, Telatar H. Interferon treatment of chronic
4. Thirteen events of poor blood flow occurred in 10
active hepatitis C in patients with and without chronic renal
patients (22.7%), the blood flow was persistently less than
failure. Gastroenterology 1994 (abst); 106: A987
150 ml per min during dialysis. Catheter cannulograms were
3. Ozyilkan E, Simsek H, Uzunalimoglu B, Telatar H. Interferon
performed in these patients, but no lumen obstruction was
treatment of chronic active hepatitis C in patients with end-stage
demonstrated. It is known that hypovolaemia may produce
chronic renal failure. Nephron 1995; 71: 156-160
poor blood flow in central venous catheters and therefore
4. Oymak O, Akpolat T. Erdem Y et al. Pretransplant alphacentral venous pressure was measured in all the patients with
interferon therapy in hemodialysis patients with hepatitis C virus
poor blood flow. In three patients the pressures were low
related chronic liver disease (letter). Nephron 1995; 69: 340
and hypovolaemia was corrected with intravenous saline,
5. Simsek H, Savas C, Tatar G, Telatar H. Treatment of chronic
which was followed by improved blood flow. In eight patients
active hepatitis C infection with interferon alpha 2a in Turkish
central venous pressures were normal and their catheters
population. J Int Med Research (in press)
were subsequently removed, however on inspection no fault
6. Hayata T, Nakano Y, Yoshizawa K, Sodeyama T, Kiyosawa K.
Effect of interferon on mtrahepatic human leukocyte antigen and
was found with the catheter to account for the poor blood
lymphocyte subsets in patients with chronic hepatitis B and C.
flow and it was assumed that the catheter tip was probably
Hepatology 1991; 13: 1022-1028
touching the vessel wall during the outflow phase of dialysis.
New catheters were inserted in these patients into the left
internal jugular veins whilst waiting for their fistulae to
mature.
Prospective study of percutaneous jugular vein catheters
for long term haemodialysis catheters
Altogether 10 catheters (22.7%) were removed due to
complications. The catheter survival at 3 months was 72.7%,
at 6 months 50%, 12 months 38.6% and 30 months 36.4%.
Sir,
We found the papers published in your Journal on permanent Eight patients died (24.2%) of catheter unrelated causes but
haemodialysis central venous catheters [1-4] valuable. We with functioning catheters at the time of death.
We would like to reduce (i) the exit site infection rate
have been interested in complications associated with permanent haemodialysis catheters in our unit and collected further and have started treating nasal carriers of staphylococdata from January 1992 to July 1994 in our renal unit in a cus aureus with Mupirocin ointment as recommended elseDistrict General Hospital, with a catchment area of 200 000 where [6], (ii) reduce problems with blood flow by using
population and a take-on rate of 20 new patients with end- catheters with distal holes as advised by Meester et al. [1].
stage renal failure for renal replacement therapy (100 new To improve first pass successful venous cannulation, we are
patients per million population per year). Fifty per cent of going to use ultrasonic guidance which should reduce perifurther 24-34 months, and serum ALT levels remained within
the normal range with a well-functioning renal graft [3,4].
Since interferons are natural proteins with antiviral and
immunomodulating functions, they have been used successfully in patients with chronic HCV infections [5]. Our
preliminary study showed that INFs are safe and effective in
the treatment of haemodialysis adult patients with chronic
HCV infection. Furthermore, initial biochemical complete
response are better in patients with CRF than in patients
without CRF.
Chronic uraemia causes a profound impairment of the
immune system and INF may correct this and may lead a
higher response rate in haemodialysis patients. INF enables
better host control on immune-system-mediated lysis of
infected hepatocytes in haemodialysis patients, in addition
to its antiviral action [6].
Decision on renal transplantation in patients with chronic
HCV infection is difficult, because of the possibility of
progression of liver disease during immunosuppressive
therapy. We followed our four patients over 2 years (range
24-34 months) after kidney transplantation without any
abnormalities in serum ALT levels and without any increased
number of rejection episodes. Our study supports the idea
that INF is a safe drug for the treatment of chronic HCV
infection in haemodialysis patients. Furthermore, INF
therapy may offer a chance for renal transplantation in these
patients. However, data for such patients are limited and
more studies are necessary.