[Renaliste] RE : Verrou anticoagulant

[Patrick GIRAUD]

Le 14/09/06 9:00, « lobbedez-t » <lobbedez-t at chu-caen.fr> a écrit :

> le verrou citrate haute concentration était plus efficace en terme de
> prevention de l'infection que heparine (JASN ?), donc ce n'est peut être pas
> qu'une question ideologique-:))
> 
Exact !! C¹est très récent ...
Je ne l¹avais pas vu passer ... Donc à lire en détail... ( résumé ci-dessous
)
Si cette conclusion s¹impose comme un preuve, 2 approches seront peut-être
possibles :
* Citralock systématique chez tous les porteurs de cathéters ( coût limitant
? ) 
* Héparine tant que tout va bien, et Citralock chez tout patient ayant eu un
antécédent d¹infection ou de contamination...

Qui a déjà fait ce genre de choix ?


> Enfin la DP permet d'eviter ou de réduire l'utilisation des KT centraux,
> notamment tunnelisé...

Certes !! Voilà encore un sujet où nous allons devoir ( moi le premier )
rendre nos choix plus argumentés et moins idéologiques ... :-))

P. Giraud 


Weijmer MC, et al...
Randomized, clinical trial comparison of trisodium citrate 30% and heparin
as catheter-locking solution in hemodialysis patients.
J Am Soc Nephrol. 2005 Sep;16(9):2769-77.
Interdialytic hemodialysis catheter-locking solutions could contribute to a
reduction of catheter-related complications, especially infections. However,
they can cause side effects because of leakage from the tip of the catheter.
Recently, trisodium citrate (TSC) has been advocated because of its
antimicrobial properties and local anticoagulation. In a multicenter,
double-blind, randomized, controlled trial, TSC 30% was compared with
unfractionated heparin 5000 U/ml for prevention of catheter-related
infections, thrombosis, and bleeding complications. The study was stopped
prematurely because of a difference in catheter-related bacteremia (CRB; P <
0.01). Of 363 eligible patients, 291 could be randomized. The study included
98 tunneled cuffed catheters and 193 untunneled. There were no significant
differences in patient and catheter characteristics on inclusion. In the
heparin group, 46% of catheters had to be removed because of any
complication compared with 28% in the TSC group (P = 0.005). CRB rates were
1.1 per 1000 catheter-days for TSC versus 4.1 in the heparin group (P <
0.001). For tunneled cuffed catheters, the risk reduction for CRB was 87% (P
< 0.001) and for untunneled catheters was 64% (P = 0.05). Fewer patients
died from CRB in the TSC group (0 versus 5; P = 0.028). There were no
differences in catheter flow problems and thrombosis (P = 0.75). No serious
adverse events were encountered. Major bleeding episodes were significantly
lower in the TSC group (P = 0.010). TSC 30% improves overall patency rates
and reduces catheter-related infections and major bleeding episodes for both
tunneled and untunneled hemodialysis catheters. Flow problems are not
reduced.


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