RECIRKULACIJA UREJE I UČINKOVITOST DIJALIZE PRI UPORABI DVOLUMINALNIH DIJALIZNIH KATETERA RAZLIČITE LOKALIZACIJE: SMIJE LI SE VENSKI KRAK KATETERA RABITI KAO ARTERIJSKI I OBRNUTO?

Siniša Šefer, Petar Kes, Vesna Degoricija, Branko Heinrich, Mislav Vrsalović

Sažetak. Cilj: Mjerenje postotka recirkulacije ureje (PRU) tijekom hemodijalize (HD) uz uporabu centralnih venskih katetera (CVK) na različitim lokalizacijama (jugularni, supklavijski i femoralni) u uvjetima kada se venski lumen katetera rabi kao arterijski i obrnuto te utvrđivanje učinkovitost HD-a na temelju mjerenja postotka sniženja ureje (PSU). Metode: PRU mjeren je u bolesnika s akutnim (AZB) i kroničnim zatajenjem bubrega (KZB) u kojih je HD provo|en uporabom privremenog dvoluminalnog CVK na različitim lokalizacijama (jugularni n=16, supklavijski n=20 i femoralni n=20) i u uvjetima kada je arterijski dio krvne linije bio spojen s arterijskim krakom katetera, a venski dio krvne linije s venskim krakom katetera (ispravan način spajanja=R1), odnosno u uvjetima kada je arterijski dio krvne linije bio spojen s venskim krakom katetera, a venski dio krvne linije s arterijskim krakom katetera (obrnuti način spajanja=R2). Učinkovitost HD-a procijenjena je mjerenjem PSU pri obrnutom načinu spajanja krvnih linija i krakova katetera. Rezultati: Utvrđena je statistički značajna razlika između R1 i R2 za jugularne katetere (R1=2,38±1,09%; R2=7,59±1,42%; n=16; p=0), supklavijske katetere (R1=3,03±3,15%; R2=15,8±7,18%; n=20; p=0) i femoralne katetere (R1=9±6,56%; R2=29,2±11,8%; p=0). Postojala je statistički značajna razlika između R1 jugularnih i R1 supklavijskih katetera (2,38±1,09%; n=16 i 3,03±3,15%; n=20; p=0,0001), izme|u R1 jugularnih i R1 femoralnih katetera (2,38±1,09%; n=16 i 9±6,56%; n=20; p=0) te izme|u R1 supklavijskih i R1 femoralnih katetera (2,38±1,09%; n=20 i 9±6,56%; n=20; p=0,0001). Statistički značajnu razliku utvrdili smo i izme|u R2 za jugularne i supklavijske katetere (7,59±1,42%; n=16 i 15,8±7,18%; n=20; p=0,0003), za jugularne i femoralne katetere (7,59±1,42%; n=16 i 29,2±11,8%; n=20, p=0,0007) te za supklavijske i femoralne katetere (15,8±7,18%; n=20 i 29,2±11,8%; n=20; p=0,0029). Mjerenjem PSU na pojedinim kateterima uz uvjete R2 utvrđena je statistički značajna razlika između femoralnih i supklavijskih katetera (51,45±5,62%; n=20 i 63,75± 7,61%; n=20; p=0) te između femoralnih i jugularnih katetera (51,45±5,62%; n=20 i 64,3±5,23%; n=16; p=0). Nije utvrđena statistički značajna razlika u PSU između jugularnih i supklavijskih katetera (64,3±5,23; n=16 i 63,75±7,61%; n=20; p=0,8). Zaključak: Provođenjem HD-a uz pravilno spajanje krvnih linija i krakova dijaliznog katetera PRU manji je od 5% kod jugularnih i supklavijskih katetera, a iznosi 5–10% kod femoralnih katetera. Uz uporabu venskoga kraka katetera kao arterijskoga i obrnuto, PSU je bio jedino kod jugularnih katetera ispod 10%, dok je kod femoralnih bio veći od 20%. Unatoč relativno visokom PRU pri ovakvu načinu uporabe katetera, PSU je nakon HD-a tijekom kojih su kao krvo`ilni pristup rabljeni jugularni i supklavijski kateteri, bio veći od 60%. Kada su za HD rabljeni obrnuto spojeni arterijski i venski krakovi femoralnih katetera, PSU je bio značajno niži te stoga treba izbjegavati ovaj način njihove uporabe.

Summary. Aim: To measure percentage of urea recirculation in hemodialysis by a dual-lumen central venous catheters of various localisations (e.g. jugular, subclavian and femoral), and also in cases when the venous lumen of the catheter is used as arterial lumen, and vice versa, and under these conditions to evaluate the efficiency of hemodialysis based on the measurements of urea reduction ratio. Methods: Percentage of urea recirculation was measured in the patients with acute and chronic renal failure who underwent hemodialysis by a temporary dual-lumen central venous catheter of different localisations (jugular n=16, subclavian n=20, femoral n=20). The measurements were done in cases when arterial line was connected to arterial lumen of the catheter, and venous line to the venous lumen of the catheter (correct connection = RI), and vice versa, i.e., when arterial line was connected to venous lumen of the catheter, and venous line was connected to arterial lumen of the catheter (reversed connection = R2). The efficiency of hemodialysis was evaluated by measuring urea reduction ratio in cases with the reversed (R2) connection. Results: Statistically significant differences were found between R1 and R2 for jugular catheters (R1=2.38±1.09%, R2=7.59±1.42%, n=16, p=0), for subclavian catheters (R1=3.03±3.15%, R2=15.8±7.18, n=20, p=0), and for emoral catheters (R1=9±6.56%, R2=29.2±11.8%, n=20, p=0). Statistically significant differences were also found between R1 of jugular catheters and R1 of subclavian catheters (2.38±1.09%, n=16 and 3.03±3.15%, n=20, p=0.0001), further on between R1 of jugular and R1 of femoral catheters (2.38±1.09%, n=16 and 9±6.56%, n=20, p=0), as well as between R1 of subclavian and R1 of femoral catheters (2.38±1.09%, n=20 and 9±6.56%, n=20, p=0.0001). Also statistically significant differ- ences were found between R2 of jugular and subclavian catheters (7.59±1.42%, n=16 and 15.8±7.18%, n=20, p=0.0003), between R2 of jugular and femoral catheters (7.59±1.42%, n=16 and 29.2±11.8%, n=20, p=0.0007), and between R2 of subclavian and R2 of femoral catheters (15.8±7.18%, n=20 and 29.2±11.8%, n=20, p=0.0029). The measurements of urea reduction ratio that we have done for some of the catheters under R2 conditions showed a statistically significant difference between femoral and subclavian catheters (51.45±5.62%, n=20 and 63.75±7.61, n=20, p=0), and between femoral and jugular catheters (51.45± 5.62%, n=20 and 64.3±5.23%, n=16, p=0). No statistical differences were found in urea reduction ratio between jugular and subclavian catheters (64.3±5.23, n=16 and 63.75±7.61%, n=20, p=0.8). Conclusion: When hemodialysis is delivered by a correct blood lines connection the measurements have shown a decrease in urea recirculation by 5% for jugular and subclavian catheters, and 5%–10% for femoral catheters. However, in cases when the venous lumen of the catheter is used as an arterial lumen, and vice versa, urea recirculation is below 10% for jugular catheters; whereas in femoral catheters the percentage is higher than 20%. Despite so high percentage of urea recirculation, that we obtained for such use of the catheters, urea reduction ratio in hemodialysis via jugular and subclavian catheters is >60%, whereas via femoral catheters, the percentage is significant- ly lower. Consequently, the efficiency of hemodialysis is reduced, and such use of femoral catheters should therefore be avoided.