Pediatric Nephrology Fellow The Hospital for Sick Children Toronto, Ontario, Canada
Background: Central venous line (CVL)-associated bloodstream infections (CLABSI) are common in pediatric hemodialysis (HD) patients and are associated with significant morbidity and healthcare costs. Unlike standard locking solutions (e.g., heparin and alteplase), 4% tetrasodium EDTA (Kitelock™) has antimicrobial and antibiofilm properties. Objective: We aimed to study the safety and efficacy of Kitelock™ in pediatric HD patients. Design/Methods: Single-center, before-and-after, quality improvement study. We included all chronic HDpatients (6mo-18yr old) and excluded those with EDTA allergy or < 5kg. Our standard locking solution was heparin (1000 units/mL) pre-intervention and Kitelock™ post-intervention. For both study periods, alteplase (1mg/mL) was used as required. We compared unit-level pre- and post-intervention data for CLABSI, CVL procedures (exchange or removal and reinsertion following antibiotic therapy), laboratory results, alteplase utilization, and access complications (e.g., alarms, exit site pain). Results: We present preliminary data for 18 patients (median age 14yr, 53% female, median 1-month since CVL insertion). The unit-level incidence rate of CLABSI pre-Kitelock™ was 0.9 events per 1000 catheter-days (25,769 total catheter-days). There have been no CLABSI events since Kitelock™ was introduced (4319 total catheter-days). The incidence rate of CVL procedures decreased from 1.99 per 1000 catheter days pre-Kitelock™ (4027 total catheter-days) to 0.93 per 1000 catheter-days post-Kitelock™ (4319 total catheter-days) (incidence rate ratio 0.47, 95%CI 0.14-1.55, p=0.2). There was no significant difference in alteplase use (12.0% of sessions pre vs. 12.3% post), HD adequacy (mean [SD] monthly stdKt/V 2.85 [0.67] pre vs. 2.81 [0.58] post), or access complications (12.0% of sessions pre vs. 12.0% post). The mean cost of locking solutions per HD session increased from $20.71 to $25.40 (CAD). Significant calcium, magnesium, and iron chelation was observed with labs drawn from the CVL with small discard volumes ( < 5mL), but not after a larger discard (≥6mL), or a small discard plus flushing protocol. We noted increased viscosity of the CVL discard using Kitelock™, which resolved with continued use.
Conclusion(s): In pediatric HD patients, CVL locking with Kitelock™ has resulted in a sustained unit-level reduction in CLABSI incidence, without an increase in the incidence of CVL procedures or access complications. Significant heavy metal chelation was observed with small discard volumes and was addressing using a CVL bloodwork withdrawal and flushing protocol. Figure 1.jpeg
