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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.