Letter to the Editor Received: October 17, 2014 Accepted after revision: February 13, 2015 Published online: March 19, 2015
Blood Purif 2015;39:238 DOI: 10.1159/000381007
The Urokinase Lock-Therapy for Hemodialysis Occluded Central Venous Catheters Gioacchino Li Cavoli Onofrio Schillaci Carmela Zagarrigo Franca Servillo Tancredi Vincenzo Li Cavoli Mattia Palmeri Ugo Rotolo Nephrology and Dialysis, Civic and Di Cristina Hospital, Palermo, Italy
Dear Editor, The recent trend among an increasing number of patients is the use of Central Venous Catheters (CVC) to perform hemodialysis (HD) [1]. The thrombosis-related malfunction of CVC is a frequent event with a significant impact on both the patient and the Nephrology Departments. The malfunction of the CVC is directly proportional to the time of existence and the vessel wall-related rheological factors [2]. Thrombolytic drugs are commonly used as a first-line treatment for clotted hemodialysis catheters. No thrombolytic agent has so far been specifically indicated for the management of occluded hemodialysis catheters. The reported efficacy of urokinase for restoring patency of occluded hemodialysis catheters has ranged from 14 to 100% [3]. The review of recent literature shows that declotting can be done with ‘high-dose’ or ‘low-dose’ lock urokinase therapy, but no consensus exists on the adequate dose to obtain thrombolysis [4–6].
From October 2000 until September 2014, we used the following protocol of CVC declotting through urokinase lock-therapy: we filled each lumen of CVC with 10,000 UI of urokinase + 1,000 UI of sodium heparin (total volume 2 ml); after 30 min this solution was drawn off. According to protocol we performed this instillation 5 times (at 0, 30, 60, 90 and 120 min); after 30 min the last dose was drawn off. We then started the HD treatment. We treated 94 patients with thrombosis-related malfunction of CVC; catheter function was restored in 90% of patients with no side effects, during the observed period. Hemodialysis treatment was performed immediately after urokinase therapy with blood speed >150 ml/min in all patients. We did not practice the ‘pushprotocol’ to avoid the systemic administration of the drug. To avoid the systemic anticoagulation in uremic patients, who are often found with hemorrhagic pathology, we filled each lumen of CVC with uroki-
nase in a sufficient quantity (2 ml) to reach the tip of the catheter but avoided injection into the systemic circulation. Although we often observed an early successful outcome after the first instillation, we always repeated, according to protocol, the ‘locks’ to improve the catheter patency. The administration protocol of multiple low-dose urokinase is an effective method for restoring hemodialysis catheter patency. In our Department the cost of 1 vial of Urokinase Hospira 100,000 IU is EUR 55. The total time of drug administration is 2 h. The instillation of urokinase is a cost-effective and safe thrombolytic therapy to declot the occluded CVC. We did not observe any adverse outcomes.
3 Twardowski ZJ: The clotted central vein catheter for haemodialysis. Nephrol Dial Transplant 1998;13:2203–2206. 4 Northsea C: Using urokinase to restore patency in double lumen catheters. ANNA J 1994; 21:261–264, 273.
5 Meers C, Toffelmire EB: Urokinase efficacy in the restoration of hemodialysis catheter function. J CANNT 1998;8:17–19. 6 Shavit L, Lifschitz M, Plaksin J, Grenader T, Slotki I: High dose urokinase for restoration of patency of occluded permanent central venous catheters in hemodialysis patients. Clin Nephrol 2010;74:297–302.
Disclosure Statement
The Authors have declared that no conflict of interest exists.
1 Zacharias JM, Weatherston CP, Spewak CR, Vercaigne LM: Alteplase versus urokinase for occluded hemodialysis catheters. Ann Pharmacother 2003;37:27–33. 2 Di Iorio BR, Mondillo F, Bortone S, Nargi P, Capozzi M, Spagnuolo T, et al: Fourteen years of hemodialysis with a central venous catheter: mechanical long-term complications. J Vasc Access 2006;7:60–65.
© 2015 S. Karger AG, Basel 0253–5068/15/0393–0238$39.50/0 E-Mail [email protected] www.karger.com/bpu
Dr. Gioacchino Li Cavoli Via Francesco Cilea 43 IT–90144 Palermo (Italy) E-Mail gioacchinolicavoli @ libero.it
Downloaded by: University of Tokyo 157.82.153.40 - 5/26/2015 6:40:55 PM
References
Blood Purif 2015;39:238 DOI: 10.1159/000381007
The Urokinase Lock-Therapy for Hemodialysis Occluded Central Venous Catheters Gioacchino Li Cavoli Onofrio Schillaci Carmela Zagarrigo Franca Servillo Tancredi Vincenzo Li Cavoli Mattia Palmeri Ugo Rotolo Nephrology and Dialysis, Civic and Di Cristina Hospital, Palermo, Italy
Dear Editor, The recent trend among an increasing number of patients is the use of Central Venous Catheters (CVC) to perform hemodialysis (HD) [1]. The thrombosis-related malfunction of CVC is a frequent event with a significant impact on both the patient and the Nephrology Departments. The malfunction of the CVC is directly proportional to the time of existence and the vessel wall-related rheological factors [2]. Thrombolytic drugs are commonly used as a first-line treatment for clotted hemodialysis catheters. No thrombolytic agent has so far been specifically indicated for the management of occluded hemodialysis catheters. The reported efficacy of urokinase for restoring patency of occluded hemodialysis catheters has ranged from 14 to 100% [3]. The review of recent literature shows that declotting can be done with ‘high-dose’ or ‘low-dose’ lock urokinase therapy, but no consensus exists on the adequate dose to obtain thrombolysis [4–6].
From October 2000 until September 2014, we used the following protocol of CVC declotting through urokinase lock-therapy: we filled each lumen of CVC with 10,000 UI of urokinase + 1,000 UI of sodium heparin (total volume 2 ml); after 30 min this solution was drawn off. According to protocol we performed this instillation 5 times (at 0, 30, 60, 90 and 120 min); after 30 min the last dose was drawn off. We then started the HD treatment. We treated 94 patients with thrombosis-related malfunction of CVC; catheter function was restored in 90% of patients with no side effects, during the observed period. Hemodialysis treatment was performed immediately after urokinase therapy with blood speed >150 ml/min in all patients. We did not practice the ‘pushprotocol’ to avoid the systemic administration of the drug. To avoid the systemic anticoagulation in uremic patients, who are often found with hemorrhagic pathology, we filled each lumen of CVC with uroki-
nase in a sufficient quantity (2 ml) to reach the tip of the catheter but avoided injection into the systemic circulation. Although we often observed an early successful outcome after the first instillation, we always repeated, according to protocol, the ‘locks’ to improve the catheter patency. The administration protocol of multiple low-dose urokinase is an effective method for restoring hemodialysis catheter patency. In our Department the cost of 1 vial of Urokinase Hospira 100,000 IU is EUR 55. The total time of drug administration is 2 h. The instillation of urokinase is a cost-effective and safe thrombolytic therapy to declot the occluded CVC. We did not observe any adverse outcomes.
3 Twardowski ZJ: The clotted central vein catheter for haemodialysis. Nephrol Dial Transplant 1998;13:2203–2206. 4 Northsea C: Using urokinase to restore patency in double lumen catheters. ANNA J 1994; 21:261–264, 273.
5 Meers C, Toffelmire EB: Urokinase efficacy in the restoration of hemodialysis catheter function. J CANNT 1998;8:17–19. 6 Shavit L, Lifschitz M, Plaksin J, Grenader T, Slotki I: High dose urokinase for restoration of patency of occluded permanent central venous catheters in hemodialysis patients. Clin Nephrol 2010;74:297–302.
Disclosure Statement
The Authors have declared that no conflict of interest exists.
1 Zacharias JM, Weatherston CP, Spewak CR, Vercaigne LM: Alteplase versus urokinase for occluded hemodialysis catheters. Ann Pharmacother 2003;37:27–33. 2 Di Iorio BR, Mondillo F, Bortone S, Nargi P, Capozzi M, Spagnuolo T, et al: Fourteen years of hemodialysis with a central venous catheter: mechanical long-term complications. J Vasc Access 2006;7:60–65.
© 2015 S. Karger AG, Basel 0253–5068/15/0393–0238$39.50/0 E-Mail [email protected] www.karger.com/bpu
Dr. Gioacchino Li Cavoli Via Francesco Cilea 43 IT–90144 Palermo (Italy) E-Mail gioacchinolicavoli @ libero.it
Downloaded by: University of Tokyo 157.82.153.40 - 5/26/2015 6:40:55 PM
References
