استفاده از استرپتوکیناز برای بازکردن مجدد کانال کلتترهای عروقی دیالیز،یک روش کم هزینه وبی خطر وموثر

Title

The use of streptokinase for restoration of patency to hemodialysis central venous catheters: a low-cost, safe and effective option

English Abstract

The use of vascular access catheter for hemodialysis is associated with a relatively high rate of complications, the most frequent of which is thrombosis. Catheter-related thrombosis has been reported in 0.06 to 21 per 1000 catheter-days, or in 0.6% to 33% of placed catheters (1). Thrombolytic agents seem to be the ideal candidate for the treatment of thrombosis associated with hemodialysis vascular catheters in most cases (2). Although alteplase, reteplase, and tenecteplase are appropriate options for thrombolytic therapy, they have a higher acquisition cost than alternative thrombolytic agents, and are not easily accessible. Therefore, this study aimed to evaluate the efficacy of streptokinase in restoring patency to hemodialysis central venous catheters. In this quasi-experimental study, hemodialysis patients who were referred to the Department of Nephrology, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran from January 2013 to December 2014 were identified. A total of 23 hemodialysis patients with catheter occlusion (13 men, 10 women; mean age, 60.5 ± 12.5 years; range, 32-88 years) were enrolled and followed prospectively for a period of 6 months. Occluded central venous catheter was defined as the difficulty infusing or withdrawing fluid from their paths. Patients who met any of the following criteria were excluded from the study: (a) receipt of any thrombolytic agent within 24 hours of enrollment; (b) high-risk patients for bleeding events and embolic complications; (c) history of coagulation disorders; and (d) allergy to streptokinase. A vial containing 1,500,000 international unit (IU) of streptokinase was diluted with 10 cc of 0.9% normal saline solution. Each lumen of the catheter was injected with 1.5 mL of the solution (containing 225,000 IU of streptokinase). Successful flushing of the catheter was indicated by easy withdrawal of blood from the catheter into the 10-cc syringe and the possibility of dialysis at ≥300 rounds per minute. If necessary, the injections were repeated up to three times in 10-minute intervals. Statistical analyses were performed using IBM SPSS® for windows software version 19.0 (SPSS Inc., Chicago, IL, USA). Known risk factors of chronic kidney failure were present in 21 patients (91.3%). The existing underlying risk factors were hypertension (84%), diabetes (52%), vasculitis (27%), and multiple myeloma (2%). The mean duration of catheterization was 7.0 ± 6.7 months. After streptokinase administration, function was restored in 21 patients (91.3%) after one to three doses. The patients who responded well to treatment were followed up for the recurrence of thrombosis. Two to four months after treatment, thrombosis recurred in four patients. Streptokinase flush injection with the described procedure resolved the problem (without any allergic reactions) in all four cases and no thrombosis was observed during the next six-month follow-up. The reinjection of streptokinase at 10-minute intervals caused no complications. In conclusion, the rate of restoration of function to occluded central venous catheters after streptokinase instillation was 91.3%. Streptokinase instillation through a central venous catheter is a low-cost, safe and effective option in restoring patency to occluded catheter.

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