Repeated low-dose streptokinase infusions into occluded permanent, central-venous hemodialysis catheters.

Several studies have reported the use of fibrinolytic therapy to re-establish the patency of arterio-venous shunts and fistulas in patients undergoing chronic maintenance hemodialysis [1—7]. In recent years the indwelling Hickman central—venous catheter has been employed as a temporary or permanent access device in patients when more conventional access becomes impossible or when immediate needs for dialysis preclude other alternatives [81. As with other forms of vascular access, thrombosis and infection remain common problems with these newer devices [9—13]. Streptokinase and urokinase infused directly into the catheter have been used to re-establish flow in patients with occluded single and double lumen catheters placed to administer cancer chemotherapy and parenteral hyperalimentation [11, 12, 14]. Hurtubise et a! [11] used low dose instillation of 150 IU of streptokinase directly into the lumen and reported no adverse reactions; however, catheters remained in place for a mean duration of only 29 days and recurrent courses were not mentioned. Zajko et a! [12] used continuous infusions of 3000 lU/hour for twelve to 24 hours. Two of his patients had recurrent clotting episodes and developed mild skin reactions with a second exposure to streptokinase. While there is no evidence to indicate that streptokinase antigenicity and bleeding complications are dose related [15], an ideal regimen should deliver the minimum dose required to produce clot lysis and at the same time limit systemic exposure. Guidelines for fibnnolytic therapy with occluded central venous catheters are limited [11, 12, 14]. There is no information about the use of streptokinase in hemodialysis patients with occluded catheters, nor has its repeated use for recurrent loss of patency been reported. In our experience, using "low—dose" continuous infusions of streptokinase directly into the central venous catheter have been successful in re-establishing catheter patency in a high percent of treated patients with few side effects and an apparent minimal risk of sensitization. We present here the use of this technique in nine patients with multiple recurrent episodes of catheter occlusion over a three year period.