Factors That Influence Thrombus Formation in Early Catheter Dysfunction and Success of Alteplase Therapy in Children with Hemodialysis

Introduction: The vascular access modality that is often used to perform regular hemodialysis (HD) measures in children with kidney failure is a tunneled double lumen catheter (TDLC), which has increased its use from 60% in 2011 to 78% in 2014 in Indonesia. The incidence of blockage caused by thrombosis is around 50%. These conditions can occur within the first 24 hours after TDLC, and usually develop within two weeks, causing early catheter dysfunction. Alteplase (rt-PA) is a thrombolytic choice for TDLC dysfunction and heparin, streptokinase, and urokinase. This study aims to determine the factors of thrombus formation in early catheter dysfunction and the effectiveness of alteplase as a therapeutic modality. Method: This study was a case-control study with children aged 0-18 years and suffering from stage 4-5 chronic kidney disease (CKD) who underwent regular HD at Cipto Mangunkusumo National Hospital. Statistical analysis using Mann-Whitney, Chi-square, Fisher’s exact, linear regression, and receiver operating characteristic (ROC) statistical tests. The test was carried out using SPSS version 20 for Windows software. Results: During the period of January 2016 to November 2017, 111 subjects met the criteria. A total of 65 subjects (58.6%) were male, and 46 subjects (41.1%) were female. Analysis showed that each albumin level <3.5 g/dL, hemoglobin (Hb) <10 g/dL, and creatinine> 5 mg/dL were risk factors for early catheter dysfunction that improved with rt- PA (p<0, 05). In multivariate analysis, only albumin levels <3.5 g/dL were associated with early catheter dysfunction. Receiver operating characteristics (ROC) curves show that early catheter dysfunction is at risk of albumin levels with a cutoff of ≤3.71 g/dL (sensitivity of 90.9% and specificity of 52.5%) and Hb levels with a cutoff of ≤8.58 g/dL (sensitivity 54.5% and specificity 77.5%). Rt-PA therapy successfully improves the condition of early catheter dysfunction in 20/22 (90.9%) cases. There were no significant side effects on the use of rt- PA in this study. Conclusion: In children undergoing regular HD with TDLC, hypoalbuminemia <3.5 g/dL, Hb <10 g/dL, and creatinine >5 mg/dL were risk factors for early catheter dysfunction. Alteplase may be useful as a safe therapeutic option. Keywords: tunneled double lumen catheter in children, early catheter dysfunction, rt-PA

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