In Australia, infected catheters were almost universally removed and then replaced through a separate tunnel tract. Background Tunneled hemodialysis catheters often have infectious or mechanical complications that require unplanned removal and replacement, but the optimal replacement strategy is unknown. This study described the real-world use of two strategies in Australia and compared the survival of replacement catheters inserted by either strategy. Methods Observational data from the REDUcing the burden of dialysis Catheter ComplicaTIOns: a National approach trial, which enrolled a nationwide cohort of 6400 adults who received an incident hemodialysis catheter (2016–2020), was used for this secondary analysis. Tunneled catheters were replaced by either catheter exchange through the existing tunnel tract or removal and replacement through a new tract. The effect of the replacement strategy on the time to catheter removal because of infection or dysfunction was estimated by emulating a hypothetical pragmatic randomized trial among a subset of 434 patients with mechanical tunneled catheter failure. Results Of 9974 tunneled hemodialysis catheters inserted during the trial, 380 had infectious and 945 had mechanical complications that required replacement. Almost all infected hemodialysis catheters (97%) were removed and separately replaced through a new tunnel tract, whereas nephrology services differed widely in their replacement practices for catheters with mechanical failure (median=50% guidewire exchanged, interquartile range=30%–67%). Service-level differences accounted for 29% of the residual variation after adjusting for patient factors. In the target trial emulation cohort of patients with mechanical catheter failure (n=434 patients), catheter exchange was not associated with lower complication-free survival at 1, 6, or 12 months (counterfactual survival difference at 1 month=5.9%; 95% confidence interval, −2% to 14%). Conclusions Guidewire exchange for mechanical failure of catheter was not associated with lower catheter survival and may be preferable for patients. Trial registration and protocol: The trial was registered in the Australia and New Zealand clinical trials registry on the June 23, 2016 (ACTRN12616000830493)....

中文翻译：

---

出现并发症的隧道式血液透析导管的更换策略：全国队列研究


在澳大利亚，受感染的导管几乎全部被移除，然后通过单独的隧道进行更换。背景 隧道式血液透析导管通常会出现感染或机械并发症，需要计划外移除和更换，但最佳更换策略尚不清楚。这项研究描述了澳大利亚两种策略的实际使用情况，并比较了两种策略插入的替代导管的存活率。方法 减少透析导管并发症的负担：一项全国性试验的观察数据用于二次分析，该试验招募了全国范围内 6400 名接受意外血液透析导管的成年人（2016-2020 年）。隧道导管的更换方式是通过现有隧道管道交换导管或通过新管道移除和更换。通过模拟一项假设的实用随机试验，评估了更换策略对因感染或功能障碍而拔除导管时间的影响，该试验由 434 名患有机械隧道导管故障的患者组成。结果 在试验期间插入的 9974 根隧道式血液透析导管中，380 根存在感染性，945 根存在机械并发症，需要更换。几乎所有受感染的血液透析导管 (97%) 均被拔除并通过新的隧道单独更换，而肾病科服务机构在更换机械故障导管方面的做法差异很大（中位数 = 50% 更换导丝，四分位数范围 = 30%–67% ）。调整患者因素后，服务水平差异占剩余变异的 29%。 在机械导管故障患者的目标试验模拟队列中（n = 434 名患者），导管更换与 1、6 或 12 个月时较低的无并发症生存率无关（1 个月时的反事实生存率差异 = 5.9%；95 % 置信区间，-2% 至 14%）。结论 因导管机械故障而更换导丝与降低导管存活率无关，可能更适合患者。试验注册和方案：该试验于2016年6月23日在澳大利亚和新西兰临床试验注册处注册（ACTRN12616000830493）......