In patients on chronic hemodialysis, a functional native arterio-venous fistula is the vascular access of choice. It offers the best performance, the longest vascular longevity and the lowest morbidity^[1].

Central venous catheters (CVCs) are essential tools in hemodialysis, because they constitute the vascular access that can be used immediately for urgent indications in hemodialysis or in the event of temporary or permanent loss of functionality of an arterio-venous fistula^[2].

Recent data indicate that 15 to 35% of patients with chronic renal failure start chronic hemodialysis from a catheter, as their first vascular access, either because the fistula is still immature or non-functional, or because the fistula is still immature or non-functional. A preemptive transplant is not possible, and it is essential to start extra renal purification^[2].

The prevalence of its use in dialysis is variable in Western countries: 7% in Japan, 15% in France, 25% in the United States and 39 % in Canada[2].

In practice, the aging of the dialysis population, the pathologies associated with chronic renal failure, and sometimes late treatment, are all reasons mentioned for the increasing use of catheters^[3].

The internal jugular route is reserved for CVCs for the medium and long term, the sub-clavian route remaining prohibited in HD because of the greater risks of venous stenosis and especially their consequences on the arterio-venous accesses of the upper limb. The femoral route is reserved for emergency dialysis or as a last resort for the long term, as it is more often a source of dysfunction, infection and phlebitis^[4].

In addition, the use of central catheters also exposes to complications compromising the possibilities of creation of future AVF^[5]. In Mali for economic reasons, or even in the hope of stabilizing the disease, patients start dialysis urgently, most often with a central venous catheter.

Objectives

The objective of this work is to assess the complications of central venous catheterization in hemodialysis at the Point G University Hospital and to determine:

• The frequency of emergency central venous catheter use,

• The frequency of incidents and accidents related to the installation of the central venous catheter,

• The frequency of complications related to the catheter.

Methodology

Place of study

Nephrology Department of Point G CHU

Type and period of study

This was a retrospective study from January 1, 2014 to June 30, 2015.

Study population

Patients who received central venous catheterization from all hemodialysis units during the study period.

Inclusion criteria

Any patient who started dialysis on a central venous catheter and has been on dialysis for at least 07 days.

Criteria for non-inclusion

Patients admitted to hemodialysis outside the study period,

Non-hemodialysis patients who have stayed in the Nephrology department.

Data collection and analysis

A data collection sheet was completed for each participant, data entry and analysis was performed on Microsoft office 2010, and SPSS 20.0.

Ethics

The confidentiality of participants was kept in all shapes and sizes.

Central venous catheter placement procedure

The catheters are placed by the doctors of the department percutaneous with local anesthesia in a dedicated room.

Results

During the period from January 1, 2014 to June 30, 2015, approximately 276 patients underwent dialysis at the Nephrology and Hemodialysis Department of the Point G University Hospital. Among these patients, 37 began hemodialysis from an arterio-fistula. Venous. Of all hemodialysis patients, 241 underwent central venous catheterization at least once. Among this patient population, 325 catheters were used, of which 36 cases of complications (11.1%) were observed in all central venous catheterizations.

On average, more than two out of three patients received a central catheterization in order to start hemodialysis with extremes ranging from 1 to 10 catheters.

Catheterizations were much more frequent on the right side with the right jugular 45.2% (147); the right femur 39.1% (127); the left femoral 11.1% (36) and the left jugular 4.6% (14).

• The average age of our patients was 26.16 years with extremes of 19 and 60 years

• The sex ratio 0.7 was in favor of women.Housewives dominated, is 52.8% of cases.

• The majority of patients were married, is 72.2% of cases.

• More than half of the patients concerned had not reached secondary school, is 66.6%.

• All of the patients had hyperparathyroidism; 97.2% were hypertensive; 47.2 had dyslipidemia and 11.1% diabetics.

Hypertensive vascular nephropathy dominated the etiologies of renal failure with 41.7% followed by ischemic vascular nephropathy 22.2%; diabetic nephropathy 11.1% and primary glomerulopathy 8.3%.

The most common reason for dialysis was: acute lung edema in 22.2% of cases; severe metabolic acidosis 19.9%; uremic encephalopathy 19.4%; blood urea greater than 50 mm ol / L 16.7%; repeated vomiting 13.9%; hyperkalemia 2.8%; uremic pericarditis 2.8% and hypertension not controlled by drug treatment 2.8%.

The site of insertion of complicated catheters was the right femoral 66.7%; the right jugular 19.4%; the left femoral 11.1% and the left jugular 2.8%.

Half of the catheters had been placed by specialized physicians (Nephrology), ie 18 cases; general practitioners 11 cases and nephrologists 7 cases. The preferred site was the right femoral with 24 cases; the right jugular 7 cases; the left femoral 4 cases and the left jugular 1 case.

The complications which motivated the withdrawal of the catheter were thrombosis 5.2%; infection 4% and the others (chapped catheter, stenosis, diverted path, spontaneous ablation and hemorrhage) 1.8%.

The duration of catheter use was less than one month 33.3% (12); more than 6 months 30.6% (11); 3 to 6 months 19.4 (7) and 1 to 3 months 16.7 (6).

The complications observed were:

• Mechanical complications: arterial punctures 11.1% (4); hematomas 11.1% (4); hemo-thorax 2.8% (1) and pneumothorax 2.8% (1).

• Infectious complications: local 19.4% (7) and general 16.7% (6).

• Thrombotic complications 47.3% (17).

The most common clinical signs were fever 69.4% (25) and chills 30.6% (11).

Complementary laboratory tests found hyper leukocytosis in 55.6% (20); CRP positive 88.9% (32); 100% accelerated ESR (36); bacteremia (Escherichia coli, Staphylococcus aureus and coagulase negative Staphylococcus) 16.7 (6).

The outcome was favorable in 91.7% (33) of patients and death was observed in 8.3% (3).

Discussion

During eighteen months, approximately 276 patients with chronic or acute renal failure underwent hemodialysis in the Nephrology department of the CHU Point G; among these patients, some started hemodialysis from an arterio-venous fistula (AVF), is 37 patients (13.4%) which is moreover the vascular approach of choice, while others cannot not to wait for the creation of an AVF were urgently hemodialysis through a central venous catheterization, is 239 patients (86.6%). The immediate mortality of patients after catheter placement varies according to the studies from 0 to 1.25 / 1000 catheters^[1].

The patients are divided into two groups:

Those who have never had a medical follow-up, arriving straight away at the terminal stage of IRC;

Those who decide not to start the ERA, despite clear information during several nephrological consultations, supported by group and individual pre-dialysis information^[8].

All of these two categories, which require emergency care, represent 239 patients, or 86.6% of cases.

Among the patients who underwent central vsnous catheterization, 36 presented at least one complication related to the hemodialysis catheter, or 11.1% of all central venous catheters used (325).

The average age of dialysis patients in an emergency situation varies widely in the literature. The hemodialysis population in developed countries is older as 50 % are over 60 years old[9, 10]. The average age of our patients was 26.16 years with extremes of 19 and 60 years. BouchraD^[11] in 2011 reported 48.35 ± 19.1 years with extremes of 4 years and 97 years. Guillaume J. (2009)^[12] 65.2 ± 12 years old.

Before dialysis as in dialysis, the male predominance is observed in all populations of chronic renal failure studies, African^[13,14], and Western^[10,15], and could be explained by a higher frequency of kidney disease in humans with more rapid progression to renal failure^[10]. The breakdown by sex is characterized by a clear predominance of women (58.3 %). Guillaume in 2009^[12] and Bouchra in 2011^[11] reported male predominance, respectively 56% and Patients with catheters are those with the most significant comorbidities^[16,17]. In these patients with significant comorbidities, the fact of being treated with a catheter represents an additional risk for these patients, both vitally infectious, and for the outcome of the final vascular access^[18]. Co-morbidity and cardiovascular risk factors were considerable across the board.

Comorbidities in order of frequency are hyperparathyroidism (100%), high blood pressure (97.2%), heart failure (88.9%), dyslipidemia (47.2%) and diabetes (11. 1%).

The causes of chronic renal failure in order of frequency are vascular nephropathy (63.9%); diabetic nephropathy (11.1%); primary chronic glomerulonephritis (8.3%) and chronic tubulo-interstitial nephropathy (5.6%). Nephropathy is of undetermined cause in 11.1%.

Randriamanantsoa in 2011^[19] reported in a study in Madagascar nephroangiosclerosis in 38% of patients and diabetes with 22%, chronic non-diabetic glomerulopathies only affected 20% of patients. Bouchra D reports 38% of cases of vascular nephropathy and 22 % of diabetic nephropathy^[11].

The main indication for emergency hemodialysis management was acute lung edema. This is probably the consequence of the late consultation of our patients.

Two of our patients after starting hemodialysis through AVF subsequently had a thrombosis of their fistula underwent central venous catheterization.

Our study shows that the recommendations of 2002 concerning the methods of fitting CVCs are generally known and / or applied. Thus, CVC placement is performed under surgical aseptic conditions and the insertion area is covered with sterile drapes in nearly 100% of cases.

At the Point “G” CHU, psychological preparation is carried out by the doctor responsible for dialysis, who informs the patient and his family about the new treatment that he must now follow, with all the advantages and disadvantages linked to the purification. Extra-renal by informing him about the creation of a temporary vascular access. Then, the patient is taken to a dedicated catheter delivery room where there is a table; a trolley with a sink (serves as a surgical hand wash)

The nephrology department of the CHU Point G is not equipped with a vascular Doppler device, which meant that the doctors were obliged to do the puncture blindly, but also with a set of emergency drugs in case of need, no oxygen mask or debris device.

Thus, 4 cases of arterial puncture with hematoma were encountered, is 11.1%; Venous wall erosion was observed in two patients due to fibrosis secondary to multiple catheterizations. One case of hemo-thorax and pneumothorax were observed.

The right femoral vein was the most used implantation site (66.7%) followed by the right internal jugular (19.4%), the left femoral (11.1%). The jugular tract (right then left) is recommended as a first-line approach for their anatomical characteristics which give better performance, and for their low morbidity^[20]. However, the subclavian route is used less and less because of the frequency of sequel of stenosis^[21]. The femoral approach is a last resort because it exposes more infectious complications^{[22, 23]}.

Thrombosis (17 cases) and infection (13 cases) dominated the causes of catheter removal in the majority of cases. The thrombogenic risk is difficult to assess. Regarding the incidence of thrombotic complications, few studies provide reference values. A study^[16] on the follow-up of 207 catheters established that the percentage of dialysis sessions with an incident and / or manipulation is 7.1%. In our series on 17 patients in whom thrombophlebitis was suspected, which necessitated catheter removal, thrombosis was confirmed in 13 patients, is 76.5%.

Tunneled catheters expose patients to more infectious complications compared to those seen with tunneled catheters^{[11,18,24,25]}. Infection is the most common and serious complication of catheter use. The risk of infection on a central catheter is 6 to 7 times higher than on AVF^[19]. These are catheter-related infections (ILC) and catheter-related bacteremia (BLC).

In our series, 13 patients presented with an infection linked to the central venous catheter, is 36.1%. Strict adherence to protocols for handling catheters and dialysis connections and disconnection significantly reduces the incidence of infection.

The first dialysis in an emergency setting without native AVF exposes our patients who have presented with BLC or ILC to infectious complications.

Mortality linked to bacteremia in hemodialysis patients varies between 8 and 20% in the literature^[12,26]. In our series 13 patients or 36.1% presented an infection; whether localized or generalized. It is difficult to talk about epidemiology without talking about the germs most often responsible for catheter infections, Staphylococcus aureus is the most frequently cited. The germs most often encountered in our study, as in the literature, are mainly Gram positive Cocci (staphylococci aureus, white and epidermidis) and Gram negative bacilli^[17]. We have no way of diagnosing thrombosis other than Doppler ultrasound. The gold standard is still phlebography. It has been used by several teams to assess the thrombogenic risk of superior vena cava catheterization, but never, to our knowledge, of femoral catheterization^[18].

We observed two cases of death in the context of sepsis and one case of hypovolemic shock (hemorrhage).

Conclusion

Hemodialysis CVCs are essential for the proper management of an acute and chronic renal failure replacement program. They nevertheless remain advantages and disadvantages: on the one hand, they allow the first route tool for the replacement treatment of patients without permanent vascular access; on the other hand, they represent an indisputable risk factor for infection and thrombotic complications.

Strict adherence to aseptic rules when placing and handling CVCs are the main elements in preventing infectious complications. Their use should be limited in frequency and duration as much as possible. To reduce the risks associated with their use in hemodialysis, the first step should be to reduce the incidence of catheter use through early detection of chronic kidney disease and preparation of AVF prior to dialysis.

Our study allowed us to have an idea on the epidemiology of dysfunctions linked to central venous catheterization in our department and to realize the extent of the problem.

List of Abbreviations

BLC: bacteremia linked to the catheter; CHU: university hospital; CHUV: Vienna university hospital; CVC: central venous catheter; ECG: electrocardiogram; EER: extra-renal purification; AVF:arteriovenous fistula; FiO2: fraction inspired by oxygen; HD: hemodialysis; ILC: catheter-related infection; CRI: chronic renal failure; NaCl: sodium chloride; ORL: otolaryngology; PEEP: end expiratory pressure position; PFC: fresh frozen plasma; PICC: peripherally central insertion catheter; PO2: partial pressure in oxygen; PCO2: partial pressure in carbon dioxide; RRR: relative risk reduction

References

1. 1. Canaud, B., Chenine, L., Formet, C., et al.Accès veineux pour hémodialyse : technique, indications, résultats et développement futur. (2005) Par

   Pubmed| Crossref| Others

2. 2. Ethier, J., Mendelssohn, D. C., Elder, S. J., et al.Vascular acces use and outcomes: an international perspective for the dialysis outcomes and practice patterns study. (2008) Nephrol Dial Transplant23(10): 3219-3226.

   Pubmed| Crossref| Others

3. 3. Rayner, H.C., Pisoni, R.L. The increasing use of hemodialysis catheters: evidence from the DOPPS on its significance and ways to reverse it. (2010) Semin Dial23(1):6–10.

   Pubmed| Crossref| Others

4. 4. Maya, I. D., Allon,M.Outcomes of tunneled femoral hemodialysis catheters: comparison with internal jugular vein catheters. (2005) Kidney Int68(6):2886-2889.

   Pubmed| Crossref| Others

5. 5. Jean, G., Vanel, T., Chazot, C., et al.Prevalence of stenosis and thrombosis of the central veins in hemodialysis after tunneled jugular catheter. (2001) Nephrologie22(8): 501-504.

   Pubmed| Crossref| Others

6. 6. Schmalz-OttS., Monti, M., Vollenweider, P.Mise en place d’un catheter veineux central chez l’adulte. (2008) Rev Med Suisse 4 : 2349-2353.

   Pubmed| Crossref| Others

7. 7. Schmalz-OttS., Monti, M., Vollenweider, P.Mise en place d’un catheter veineux central chez l’adulte. (2008) Rev Med Suisse 4: 2343-2348.

   Pubmed| Crossref| Others

8. 8. Sylvie, L., Fabrice, G., Pascale, T., et al.Evaluation des complications infectieuses liées aux cathéters veineux centraux d’hémodialyse en Polynésie française. (2013) NephrolTher9(3) : ١٣٧–142.

   Pubmed| Crossref| Others

9. 9. Carrière, C., Marchandin, H.Infections liées aux cathéters veineux centraux : diagnostic et définitions. (2001) Néphrol22(8): 433-437.

   Pubmed| Crossref| Others

10. 10. Pouteil, N.C., Villar, E.Epidémiologie et étiologie de l’insuffisance rénale chronique. (2001) Rev Prat 51: 365-371.

    Pubmed| Crossref| Others

11. 11. Bouhra, D. Cathéters veineux centraux pour hémodialyse à propos de 118 cas. (2012) Thèse Med; N° 125 P108. Fès (Maroc).

    Pubmed| Crossref| Others

12. 12. Jean, G. Incidence and risk factors for infections from hemodialysis catheters. (2001) Nephrol22(8): 443–448.

    Pubmed| Crossref| Others

13. 13. Abderrahim, E., Ben, A., Hedri, H.Epidémiologie de l’insuffisance rénale chronique dans le nord tunisien: évolution sur une période de 10 ans. (2002) Néphrologie 23: 293.

    Pubmed| Crossref| Others

14. 14. Akinsola, W.,Odesanmi, W.O., Ogunniyi, J.O., et al. Diseases causing chronic renal failure in Nigerians- a prospective study of 100 cases. (1989) Afr J Med MedSci18(2): 131-137.

    Pubmed| Crossref| Others

15. 15. Cruz, I.A., Hosten, A.O.An updateof the end-stage renal disease program at howard university hospital. (1989) Transplant proc21(6): 3892-3894.

    Pubmed| Crossref| Others

16. 16. Ayzac, L., Beruard, M., Girard, R., et al. Présentation de Dialin : réseau de surveillance des infections chez les patients hémodialysés en centre. Premiers résultats. (2009) NephrolTher5(1):41–51.

    Pubmed| Crossref| Others

17. 17. Feldman, H.I., Kobrin, S., Wasserstein, A. Hemodialysis vascular access morbidity. (1996) J Am SocNephrol7(4): 523-535.

    Pubmed| Crossref| Others

18. 18. Vanholder, R. Vascular access. (2002) Int J Artif Organs 25: 347-353.

    Pubmed| Crossref| Others

19. 19. Randriamanantsoa, L. N., Rajaonera, T. A., Ramanamidora, D. A. H., et al.Revue d’Anesthésie. (2011) Réanimation et de Med Urg٣(2): 1-5

    Pubmed| Crossref| Others

20. 20. Canaud, B., Chenine, L., Formet, C., et al.Accès veineux pour hémodialyse : technique, indications1, résultats et développement futur. (2005) Actualités Néphrologiques 251- 271.

    Pubmed| Crossref| Others

21. 21. Clark, D.D., Albina, J.E., Chazan, J.A.Subclavian vein stenosis and thrombosis: a potential serious complication in chronic hemodialysis patients. (1990) Am J Kidney Dis15: 265-268.

    Pubmed| Crossref| Others

22. 22. Montagnac, R., Bernard, C., Guillaumie, J.et al. Indwelling silicone femoral catheters: experience of three haemodialysiscentres. (1997) Nephrol Dial Transplant12(4): 772-775.

    Pubmed| Crossref| Others

23. 23. Zaleski, G.X., Funaki, B., Lorenz, J.M.Experience with tunneled femoral hemodialysis catheters. (1999) Am J Roentgenol172(2) : 493-496.

    Pubmed| Crossref| Others

24. 24. Padberg, F.I., Roggiero, J., Blackburn, G.L., et al.Central venous catheterization for parenteral nutrition. (1981) AnnSurg193(3): 264-270.

    Pubmed| Crossref| Others

25. 25. Cardei.I.I R., D’Amicone, M., Tognarei.I.I G., et al. Complicanze immediate e a distanzadelcateterismo(1986) fcmorale per emodialisi. Min Urol Neff38: 215-217.

    Pubmed| Crossref| Others

26. 26. Kairaitis, L.K., Gottlieb, T. Outcome and complications of temporary hemodialysis catheters. (1999) Nephrol Dial Transplant14:1710–1714.

    Pubmed| Crossref| Others