Clin Exp Nephrol DOI 10.1007/s10157-015-1148-5
ORIGINAL ARTICLE
The bacterial colonization in tunneled cuffed dialysis catheter and its effects on residual renal function in incident hemodialysis patients Jin Suk Kang1 • Hee Ryeong Jang1 • Jeong Eun Lee1 • Young Joo Park1 • Harin Rhee1,2 • Eun Young Seong1,2 • Ihm Soo Kwak1,2 • Il Young Kim1 • Dong Won Lee1 • Soo Bong Lee1 • Sang Heon Song1,2
Received: 19 June 2015 / Accepted: 17 July 2015 Ó Japanese Society of Nephrology 2015
Abstract Background The bacterial colonization of hemodialysis catheter occurs frequently and reaches to the catheter-related bloodstream infections (CRBSIs). We hypothesized bacterial colonization promotes inflammation and that might be associated with renal outcome. The aim of this study was to investigate the colonization status for tunneled cuffed dialysis catheter (TCC) and the factors for contributing to the catheter colonization and explore whether bacterial colonization would be related with declining of residual renal function (RRF). Methods 115 patients who received TCC removal operation and underwent catheter tip culture from January 2005 to June 2014 were enrolled. The follow-up data such as urine output (UO), time to anuria and patients’ survival were collected from the patients or their family members by telephone in June, 2014. Results There were nineteen patients (16.5 %, 19/115) with positive tip culture (colonization group). In the analysis of demographic and biochemical parameters, there were no significant differences between both groups. Fifty of all the subjects responded to the telephone survey and ten patients (20.0 %, 10/50) belonged to colonization group. The monthly decreasing rate of UO was significantly more rapid in colonization group (p = 0.001). The survival analysis showed that colonization group had worse
& Sang Heon Song
[email protected];
[email protected] 1
Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
2
Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
estimated anuria-free survival than non-colonization group (p \ 0.001). In multivariate cox regression, bacterial colonization of TCC was an independent factor influencing the loss of RRF (HR 4.29, 95 % CI: 1.905–9.683, p B 0.001). Conclusions Bacterial colonization of TCC was associated with rapid loss of RRF. Keywords Bacterial colonization Catheter-related infection Hemodialysis Vascular access device
Introduction Hemodialysis (HD) patients with dialysis catheter have significantly higher mortality and morbidity than HD patients with arteriovenous fistula (AVF), which finding has been associated with immune activation [1–4]. Dialysis catheter infections are two- to fivefold higher than that with AVF and arteriovenous grafts (AVG) [4, 5]. The number of patients with chronic kidney disease (CKD) is increasing annually, and patients requiring renal replacement therapy are increasing as well. In South Korea, the prevalence per million population (PMP) for end-stage renal disease (ESRD) was 1353.3 and HD have occupied as 69.1 % among them in the report of 2012 Korean Society of Nephrology ESRD registry [6]. In terms of vascular access for HD, nearly 80 % of the patients have initiated treatment with central catheter, which is followed by 16.8 % AVF, and 3.4 % AVG [7]. TCC is a commonly used temporary dialysis access for bridging ESRD patients to permanent dialysis access such as AVF and AVG and can be used for weeks to months for the advantage of its low risk for extra-luminal bacterial infection compared with non-tunneled uncuffed dialysis
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catheter [8]. Furthermore, many nephrologists prefer using TCC as vascular access for dialysis in the setting of very elderly and patients who have severe vascular disease or be in the severe debilitated status [9]. Several studies showed the incidence of colonization to be 15.6–68 % of central venous HD catheter, which is associated with catheter related bloodstream infections (CRBSIs) [10–13]. Strategies to prevent colonization have been proposed and TCC colonization surveillance is useful in preventing CRBSIs [12]. Several studies investigated the factors related to colonization of dialysis catheter, they reported catheter colonization was associated with duration of catheter insertion [13]. C-reactive protein (CRP) was significantly higher in HD patients with dialysis catheter compared with AVF and its finding proposed that dialysis catheter would contribute to systemic inflammation [1, 2, 14]. Fontsere et al. studied impact of taurolidine-citrateheparin lock solution on inflammation which is encouraged by the bacterial colonization. CRP and interleukin-6 (IL-6) were significantly decreased, as well as the occurrence of CRBIs significantly reduced in the group with the solution [15]. Chronic inflammation led to increased cardiovascular risk [16] and is one of the risk factors related to loss of RRF [17, 18]. Based on these studies, we hypothesized bacterial colonization promoting inflammation might be associated with renal outcome. So, in this retrospective study we aim to uncover the colonization status for TCC as a vascular access and explore the factors for contributing to the catheter colonization. In addition, the effect of colonization on RRF was tested.
indicating whether it colonized bacteria or not and which bacteria were cultivated were also collected. To identify the change of renal function, we called the patients and their families on the phone in June 2014 to collect followup data which were the time of anuria or death and UO at the time of calling if they were not anuric. In order to assess the effect of colonization on RRF, patients with systemic inflammatory response syndrome or bacteremia that might affect deterioration of renal function were excluded. Semi-quantification of UO was done with counting numbers of a 150-mL paper cup into which they pour their urine collected over 24 h. This semi-quantification method has been included in the education program for CKD patients in our hospital. The institutional review board approved the study (E-2014085), and the need for informed consent was waived. Statistical analysis Statistical analyses were performed using SPSS for window version 18.0 (SPSS Inc., Chicago, IL, USA). All continuous variables were summarized as means and standard deviations. Categorical variables were described using frequencies and percentiles. In order to compare the means of the two groups, we used Mann–Whitney U test. In the analysis of renal and patient survival, UO and time from the initiation of HD to anuria or death were estimated using cox proportional hazard regression and Kaplan– Meier method. All results were considered significant by p \ 0.05.
Results Materials and methods
Demographic and biochemical data
Study population
A total of 115 patients were enrolled who received TCC removal and whose TCC tips were cultured. Of all the patients, 19 (16.5 %) were with positive tip culture (colonization group), and 96 (83.5 %) were negative (non-colonization group). Mean duration of TCC-inserted state was 125.6 days, and incidence of catheter colonization was 7.58/1000 catheter days. Bacteremia had occurred in 31.6 % of colonization, and incidence of bacteremia was 5.33/1000 catheter days (Table 1). The mean age of participants was 57 years. Although the average age was slightly older in the colonization group, there was no significant difference between two groups (colonization group: 61.2 ± 15.4 vs. non-colonization group: 56.2 ± 14.5 days, p = 0.133). The most common underlying disease was diabetes mellitus (DM) in both groups [colonization group: 12 (63.2 %) vs. non-colonization group: 48 (50.0 %)]. The duration of TCC-inserted state
Patients who received TCC insertion for HD and underwent catheter tip culture when removing the catheter were enrolled. Data were collected and analyzed retrospectively from January 2005 to June 2014. TCCs were usually removed with aseptic technique in the operation room under local anesthesia after AVF or AVG maturation and catheter tips were incubated at least for 5 days. Patients who stopped dialysis because of receiving kidney transplant and improving renal function were excluded. Data collection We collected biochemical and clinical parameters including urine output (UO) at the time of TCC removal from January 2005 to June 2014. TCC colonization data
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Clin Exp Nephrol Table 1 Characteristics of tunneled cuffed dialysis catheter included in the study (N = 115)
Staphylococcus aureus and Staphylococcus epidermidis (Table 4).
Characteristics
The effect of TCC colonization on RRF Total duration (days)
14,448
Mean duration (days ± SD)
125.6 ± 90.1
Cumulative colonization incidence, n (%)
19 (16.5 %)
Incidence density of colonization (/1000 catheter days)
7.58
Cumulative bacteremia incidence, n (%)
6 (5.2 %)
Incidence density of bacteremia (/1000 catheter days)
5.33
SD standard deviation
was not significantly different between two groups (colonization group: 131.8 ± 72.5 days vs. non-colonization group: 124.4 ± 93.5 days, p = 0.304). In other demographic characteristics, there were no significant differences between both groups (Table 2). In laboratory data at the time of TCC removal, there were no significant differences between two groups as well (Table 3). Microorganism in the TCC tip culture Nine different organisms were isolated in 19 colonized TCC tips. There were no tips colonized by more than one organism. Gram-positive organisms accounted for 73.7 % of isolates and 47.4 % of the gram-positive isolates were
Table 2 Comparison of characteristics between colonization group and noncolonization group
It was possible to collect follow-up data of 50 patients (43.5 % of the total study population), except for 6 patients with bacteremia, regarding UO trend, the time of anuria and death through telephone interviews. Ten patients (10/50, 20.0 %) were in colonization group and others were of non-colonization group. In the analysis of demographic and biochemical parameters of them, there were no significant differences between two groups (Tables 5 and 6). UO at the time of HD initiation was not different between two groups (colonization group: 830.0 ± 312.9 mL vs. non-colonization group: 1155.0 ± 538.7 mL, p = 0.052). The rate of decrease in UO, however, was significantly more rapid in the colonization group (colonization group: 50.1 ± 25.5 mL/month vs. non-colonization group: 24.7 ± 36.4 mL/month, p = 0.001) (Table 7). In survival analysis, patients in colonization group had significantly worse estimated anuria-free survival (log rank p \ 0.001) (Fig. 1). We analyzed the factors affecting the reduced RRF using cox regression. In univariate cox regression and multivariate cox regression, albumin and bacterial
Characteristics
Colonization
Non-colonization
Number (%)
19 (16.5)
96 (83.5)
P value
Age, mean (SD)
61.2 (15.4)
56.2 (14.5)
0.133
Sex, male (%)
9 (47.4)
46 (47.9)
0.965
BMI, kg/cm2 (SD)
22.6 (3.1)
22.7 (3.8)
Underlying causes, n (%)
0.966 0.219
DM
12 (63.2)
48 (50.0)
HT
7 (36.8)
25 (26.0)
GN
0 (0)
13 (13.5)
ADPKD
0 (0)
1 (1.0)
Others
0 (0)
9 (9.4)
Systolic BP, mmHg (SD)
141.0 (18.8)
136.5 (18.5)
0.351
Diastolic BP, mmHg (SD)
81.8 (8.7)
82.4 (10.6)
0.684
Statin, n (%)
6 (31.6)
29 (30.2)
0.906
EPO use, n (%)
18 (94.7)
76 (79.2)
0.158
Low Moderate
16 (84.2) 3 (15.8)
47 (69.8) 29 (30.2)
High
0 (0)
0 (0)
Bleeding event, n (%)
4 (21.1)
16 (16.7)
0.645
Duration, days (SD)
131.8 (72.5)
124.4 (93.5)
0.304
SD standard deviation, DM diabetes mellitus, HT hypertension, GN glomerulonephritis, ADPKD autosomal dominant polycystic kidney disease, MGUS monoclonal gammopathy of undetermined significance, BP blood pressure, EPO erythropoietin
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Clin Exp Nephrol Table 3 Laboratory data at the time of TCC removal
Colonization (N = 19) Albumin (g/dL) Cholesterol (mg/dL)
3.4 ± 0.7
3.4 ± 0.7
0.957
164.4 ± 53.6
0.116
Uric acid (mg/dL) Creatinine (mg/dL) Hemoglobin (g/dL) Ferritin (ng/mL)
6.1 ± 2.3
8.2 ± 14.0
0.175
66.4 ± 48.7
65.7 ± 38.8
0.716
7.7 ± 3.3
7.4 ± 4.1
0.853
9.6 ± 1.7
9.7 ± 2.1
0.880
7934.9 ± 5202.9
7141.6 ± 3128.1
0.761
370.8 ± 385.5
452.1 ± 575.1
0.479
69.5 ± 48.9
70.6 ± 43.3
0.707
196.5 ± 41.8
213.4 ± 45.3
0.086
32.2 ± 19.2
36.9 ± 39.7
0.847
4.9 ± 10.4
1.8 ± 3.7
0.615
Iron (ug/dL) TIBC (ug/dL)
P value
143.2 ± 36.1
BUN (mg/dL)
WBC (/uL)
Non-colonization (N = 96)
TSAT (%) CRP (mg/dL)
Data are expressed as mean ± SD TCC tunneled cuffed dialysis catheter, TIBC total iron-binding capacity, TSAT transferrin saturation (iron/ TIBC), CRP C-reactive protein
Table 4 Isolated organisms in the TCC tip culture Isolated organisms
Number of colonized tips, N (%)
Staphylococcus aureus MS MR
2 (10) 3 (15)
Staphylococcus epidermidis
4 (20)
Staphylococcus warneri
1 (5)
Coagulase negative staphylococcus MS MR
1 (5) 2 (10)
Pseudomonas aerusinosa
2 (10)
Burkholderia cepacia
1 (5)
Gram positive bacilli sporeforming
1 (5)
Gram negative bacilli sporeforming
1 (5)
Candida parapsilosis
1 (5)
TCC tunneled cuffed dialysis catheter, MS methicillin sensitive, MR methicillin resistant
colonization were related with the rate of UO decrease (Table 8).
Discussion This study aimed to reveal the colonization status for TCC as a vascular access and the relationship between the bacterial colonization of TCC and clinical outcomes in HD patients. 19 (16.5 %) of TCC became colonized, and there were no statistically significant differences in the basic characteristics and biochemical data. In follow-up data, UO
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at the initiation of HD was not significantly different between the two groups, but in the colonization group the rate of decrease in UO was more rapid and the time to anuria was shorter. Renal survival was also better in noncolonization group. In multivariate cox regression, TCC colonization was a predictor of reduction in RRF. Patients with CKD have altered immunity characterized by two aspects, which are contradictory to each other, immune activation and immunosuppression by uremia [19– 23]. Chronic inflammatory condition in HD patients is associated with endothelial damage and immune dysfunction [24, 25]. Endothelial damage by chronic inflammation is a factor affecting cardiovascular disease (CVD) [16], which is a leading cause of death among HD patients [19– 21, 26]. Immune dysfunction can also induce chronic, recurrent or subclinical infection and resultant augmentation of chronic inflammation [27–29]. Some studies revealed that chronic inflammation may be a contributing factor to decrease RRF [17, 18], and it has been well known that dialysis patients with rapidly decreasing RRF have poor survival [17, 30–32]. For example, RRF was clearly associated with 2-year mortality in 114 HD patients with and without RRF. The time to death was shorter in the absence of RRF (HR 0.35, p = 0.002) [30]. Several studies reported CRP level was significantly higher in patients with non-infected catheters than in those with AVFs [1, 3, 14]. Goldstein et al. measured the CRP level in incident HD patients, comparing those dialyzed through a non-infected catheter and through AVF. Compared to the patients who dialyzed through AVF after the HD catheter was removed (catheter–fistula group) and the patients who dialyzed through HD catheter for 6 months (catheter–catheter group), CRP level was significantly
Clin Exp Nephrol Table 5 Follow-up data: comparison of characteristics between colonization group and non-colonization group
Characteristics
Colonization
Number (%) Age, mean (SD)
P value
10 (20.0)
40 (80.0)
59.2 (16.6)
57.2 (13.1)
0.454
8 (80.0)
24 (60.0)
0.239
Sex, male (%) BMI, kg/cm2 (SD)
Non-colonization
22.7 (2.2)
23.0 (3.3)
Underlying causes, n (%)
0.825 0.468
DM
7 (70.0)
17 (42.5)
HT
3 (30.0)
10 (25.0)
GN
0 (0)
Others
0 (0)
9 (22.5) 4 (10.0)
Systolic BP, mmHg (SD)
142.0 (19.3)
137.5 (18.2)
0.561
Diastolic BP, mmHg (SD)
83.5 (11.1)
82.0 (9.7)
0.882
Statin, n (%)
5 (50.0)
13 (32.5)
0.302
10 (100.0)
31 (82.5)
0.274
Low
7 (70.0)
19 (47.5)
Moderate High
3 (30.0) 0 (0)
14 (35.0) 0 (0)
EPO use, n (%)
Bleeding event, n (%) Duration, days (SD)
1 (10.0)
7 (17.5)
0.563
117.3 (75.5)
132.5 (82.5)
0.507
SD standard deviation, DM diabetes mellitus, HT hypertension, GN glomerulonephritis, ADPKD autosomal dominant polycystic kidney disease, MGUS monoclonal gammopathy of undetermined significance, BP blood pressure, EPO erythropoietin
Table 6 Follow-up data: laboratory data at the time of TCC removal
Colonization (N = 10) Albumin (g/dL) Cholesterol (mg/dL)
Non-colonization (N = 40)
P value
3.6 ± 0.6
3.6 ± 0.7
0.957
141.9 ± 37.1
162.7 ± 55.8
0.266
Uric acid (mg/dL) BUN (mg/dL) Creatinine (mg/dL) Hemoglobin (g/dL)
5.9 ± 1.8
6.8 ± 2.4
0.305
59.7 ± 59.2
57.6 ± 30.5
0.948
8.1 ± 4.1
6.6 ± 2.8
0.448
9.2 ± 1.8
9.9 ± 1.9
0.359
6851.0 ± 2793.8
7137.3 ± 3178.1
0.729
Ferritin (ng/mL) Iron (lg/dL)
264.2 ± 168.8 70.3 ± 45.9
556.4 ± 770.6 82.1 ± 44.5
0.108 0.246
TIBC (lg/dL)
212.9 ± 34.5
219.2 ± 41.0
0.454
25.9 ± 10.3
46.1 ± 55.7
0.057
0.9 ± 1.0
1.9 ± 4.3
0.900
WBC (/lL)
TSAT (%) CRP (mg/dL)
Data are expressed as mean ± SD and bacteremia patients were excluded TCC tunneled cuffed dialysis catheter, TIBC total iron-binding capacity, TSAT transferrin saturation (iron/ TIBC), CRP C-reactive protein
decreased in catheter–fistula group (p \ 0.0001) [2]. These studies show the HD vintage is associated with chronic inflammation and dialysis catheters contribute to trigger inflammation [1, 2, 14]. However, the dynamics of catheter colonization remain uncertain. Based on the number of studies, we hypothesized bacterial colonization is triggered chronic inflammation and that might be associated with renal outcome. So, we studied colonization status for TCC and the effect of
colonization on RRF. Our study is a first report about the relations of TCC colonization with RRF. The results of this study showed that 19 (16.5 %) patients were with colonization and 6 patients (31.6 % of colonization group) were with bacteremia. Raad et al. reported colonization was occurring in 11 % of indwelling catheters and bacteremia was occurring in 3 % of them [13]. Dittmer et al. reported colonization rate was 68 % and bacteremia has occurred in 35 % of colonized catheter [10]. And Kim
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Clin Exp Nephrol Table 7 Follow-up data about renal outcomes between the groups (N = 50)
Colonization (N = 10)
Non-colonization (N = 40)
P value
830.0 ± 312.9
1155.0 ± 538.7
0.052
95.0 ± 157.1
251.0 ± 443.1
0.678
735.0 ± 278.9
904.0 ± 625.5
0.609
Time to anuria or the present (months)
21.0 ± 16.1
62.9 ± 45.0
0.003
UO decrease rate (ml/month)
50.1 ± 25.5
24.7 ± 36.4
0.001
UO at the initiation of HD (mL) UO at the time of follow-up (mL) DUO (mL)
Data are expressed as mean ± SD UO urine output, HD hemodialysis, DUO (urine output at the initiation of hemodialysis)—(urine output at the time of follow-up), UO decrease rate (mL/month) DUO/Time to anuria or the present (mL/month)
Fig. 1 Renal survival curve between colonization group and noncolonization group by Kaplan–Meier analysis (log rank p \ 0.001)
reported colonization rate was 24 % and bacteremia rate was occurring in 3 % of them [33]. The incidence of CRBSIs was 2.0 - 5.5/1000 catheter days [34–38]. In several studies, HD catheter colonization was associated with duration of catheterization [10, 13]. But there was no statistically significant difference between the duration and colonization in this study (p = 0.304). Factors such as age [39], DM [40], immunosuppression [19], low albumin [24, 34, 41] and high ferritin [42] have been found to increase the risk of CRBSIs. And duration of catheterization, bacterial colonization [10, 33], degree of colonization [10], manipulation technique and personal hygiene [42] are also
associated with the risk of CRBSIs. In the studies of the factors affecting the renal function loss, mineral metabolism (calcium and phosphate level), serum albumin, proteinuria and inflammation are well known for significant predictors of decline in RRF [17, 43]. In this study, although the mean age was slightly older in the colonization group, there was no significant difference. In multivariate cox regression, albumin and bacterial colonization of TCC were independent predictors influencing the loss of RRF. Systemic factors cannot be corrected; however, CRBSIs should be decreased through strategies to prevent colonization [12, 44] and aseptic technique [45, 46]. In study of endo-luminal TCC colonization surveillance, TCC colonization was evaluated every 15 days. Antibiotic lock therapy and antibiotic injections were performed in accordance with the identified time and cultured bacteria. As a result, CRBSIs was significantly decreased than before the treatment (0.27 episode/1000catheter days vs. 1.65 episode/1000 days, P \ 0.001) [12]. Before TCC insertion, systemic antibiotics are not routinely given in our hospital, and there is no guideline on the use of prophylactic antibiotics. When a HD session is finished, it is not also a routine to fill the TCC with concentrated antibiotic solution in most dialysis centers, but there are some studies reporting about the preventive effect of concentrated antibiotic solution such as taurolidine [36, 47], tobramycin [48], and gentamycin [49] on colonization and CRBSIs by interfering with fibrin formation and permitting increased penetration of antibiotics [50]. Given our results, it is necessary to investigate whether blocking colonization of TCC with antibiotics can affect the hard clinical outcomes of HD patients.
Table 8 Univariate and multivariate cox proportional hazard for the evaluation of UO decrease rate in survival analysis Univariate HR ratio (95 % CI)
P value
Multivariate HR ratio (95 % CI)
P value
Albumin (g/dL)
0.553 (0.338–0.904)
0.018
0.549 (0.332–0.909)
0.020
Colonization
4.340 (1.921–9.805)
0.001
4.295 (1.905–9.683)
0.000
HR hazard ratio
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Clin Exp Nephrol
In conclusion, although we cannot reveal the factors affecting colonization, bacterial colonization of TCC was a predictor of RRF loss in incident HD patients. In future, the relationship should be confirmed through large-scale prospective study for further popular use of TCC in the view point of safety.
16.
Compliance with ethical standards
18.
Conflict of interest
17.
None.
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