Understanding the risk of dialysis for LTC residents
Sireesha Koppula, MD, MPH
One in 10 American adults have some level of Chronic Kidney Disease. As baby boomers age, increasing their risk of diabetes and obesity, it's likely many also will experience decline in kidney function.
Currently, people older than 75 make up the fastest growing segment of the population initiating dialysis each year. It becomes clear that the needs of hemodialysis patients require special consideration in skilled nursing and long-term care environments.
Central venous catheters were originally for short-term dialysis, but have become the permanent dialysis access in patients who have limited other options because of poor vasculature. Despite the risks associated with hemodialysis catheters, the relative use of the permanent dialysis catheters has increased steadily. Here, we will focus on a specific danger to dialysis patients: catheter-related bloodstream infections.
The most frequent and typical kinds of infections in the long-term care setting are urinary tract infections, respiratory infections, and skin and soft tissue infections. Patients who have a hemodialysis catheter face an additional risk. They are more than 100 times more likely than other people to get a bloodstream infection from methicillin-resistant Staphylococcus aureus, a common antibiotic resistant bacteria.
Every time an end stage renal disease patient goes to dialysis, the catheter gets exposed to the bacteria from skin and needles. This happens three times a week. Bacteria from the skin can migrate along the outside of the catheter into the blood stream. The longer patients have the catheter, the greater the risk that bacteria inside the catheter (from the biofilm) are released into the patient's bloodstream causing serious infection.
These infections can be exit site infections, where there is pus at the exit site of the dialysis catheter, or they can become life threatening and spread throughout the body. Between 21% and 31% of hemodialysis patients with S. aureus bloodstream infections can develop complications such as an infected heart valve (endocarditis) or bone infection (osteomyelitis). Patients with an S. aureus infection could require hospitalization for an average of 9-13 days.
The symptoms of catheter-related bloodstream infections are among those that nurses typically look out for—fever, a rapid heart rate, shaking chills, low blood pressure, gastrointestinal symptoms (such as abdominal pain, nausea, vomiting, and diarrhea), rapid breathing, and/or becoming confused. The condition is confirmed by concurrent cultures from the patient's blood and from the hemodialysis catheter showing that the same type of bacteria is present in both.
The good news is healthcare providers are paying more attention. In April 2009, the CDC launched a collaborative project with dialysis centers across the United States to prevent bloodstream infections among dialysis patients and develop infection prevention guidelines. That led to a 32% decrease in overall bloodstream infections and a 54% decrease in vascular access-related bloodstream infections among dialysis patients. The CDC's guidelines included chlorhexidine (an antiseptic for the skin) for catheter exit-site care and antimicrobial ointment on central line exit sites as well as staff training and competency assessments focused on catheter care and sterile technique, hand hygiene and vascular access care audits.
Meanwhile, researchers are exploring new tools to help prevent these infections. A number of doctors around the country are participating in a trial called LOCK-IT-100 testing whether an investigational new drug solution called Neutrolin could provide additional help in safely preventing catheter-related infections and blood clots when instilled into the patient's central venous/dialysis catheter at the end of the dialysis session. More information about this trial and other ongoing studies to examine the prevention and treatment of catheter related bloodstream infections can be found at www.clinicaltrials.gov.
Researchers, doctors, nurses, patients and caregivers have already gone a long way in preventing catheter related bloodstream infections. As new products become available and techniques continue to develop, we can make these hemodialysis catheter infections rare each year.