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Observational Study
. 2021 May;36(5):1245-1254.
doi: 10.1007/s00467-020-04743-9. Epub 2020 Oct 30.

Silent and dangerous: catheter-associated right atrial thrombus (CRAT) in children on chronic haemodialysis

Martin Garcia-Nicoletti  1 , Manish D Sinha  1   2 , Alexandra Savis  3 , Shazia Adalat  1 , Narayan Karunanithy  4   5 , Francis Calder  6   7
Affiliations
Observational Study

Silent and dangerous: catheter-associated right atrial thrombus (CRAT) in children on chronic haemodialysis

Martin Garcia-Nicoletti et al. Pediatr Nephrol. 2021 May.

Abstract

Background: Catheter-associated right atrial thrombus (CRAT) is a recognised complication of central venous catheter (CVC) use for haemodialysis (HD) patients.

Methods: This was a single-centre retrospective longitudinal observational study of consecutive children aged 6 months-18 years over a 7-year period receiving in-centre chronic HD. Echocardiograms as per routine cardiac surveillance were performed 6 months or earlier given clinical concerns.

Results: Sixty-five children, 36 boys (55.4%), median (IQR) age 11.8 (5.3, 14.7) years, received HD for kidney failure with replacement therapy (KFRT). Initial modality was HD in 45 (69.2%), with CVC as initial access in 42 (93.3%) and AVF in 3 (6.7%); in the remaining 20 (30.8%) patients PD was the initial modality before switching to HD. Seven of 65 (10.8%) developed CRAT at median 2 (0.8, 8.4) months from CVC insertion, with one CRAT detected 3 days following insertion. One child had 2 episodes of CRAT and one additionally thrombosed their AVF. No patient had an underlying primary kidney disease associated with a pro-thrombotic state. Those with CRAT were younger, had more frequent CVC change and received dialysis for longer duration compared to those with no CRAT. Six episodes of CRAT (75%) received anticoagulation therapy. Infective complications were observed in 25% and catheter malfunction in 50%. Five CRAT episodes (62.5%) resulted in CVC loss. One patient died after a haemorrhagic complication of anticoagulation and sepsis, and another developed life-threatening superior vena cava obstruction syndrome. Overall mortality 14% (1/7).

Conclusions: This is the first report of CRAT in a paediatric HD population. There was ~ 11% incidence of CRAT in patients receiving chronic HD detected by surveillance echocardiography. Although frequently asymptomatic, CRAT is associated with serious sequelae. Anticoagulation and surveillance with expert echocardiography remain mainstays of management. Graphical abstract.

Keywords: Arteriovenous; CRAT; CVC; Catheter-associated right atrial thrombi; Children; Fistula; KFRT; Right atrium; Thrombus; Tunnelled.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Clinical algorithm for the clinical management of children with catheter-related atrial thrombus (CRAT)
See this image and copyright information in PMC

References

    1. Shroff R, Calder F, Bakkaloğlu S, Nagler EV, Stuart S, Stronach L, Schmitt CP, Heckert KH, Bourquelot P, Wagner AM, Paglialonga F, Mitra S, Stefanidis CJ, European Society for Paediatric Nephrology Dialysis Working Group Vascular access in children requiring maintenance haemodialysis: a consensus document by the European Society for Paediatric Nephrology Dialysis Working Group. Nephrol Dial Transplant. 2019;34:1746–1765. doi: 10.1093/ndt/gfz011. - DOI - PubMed
    1. Renal replacement therapy and conservative management NG107 (2018) Available at: www.nice.org.uk/guidance/ng107. Accessed 09/05/2020
    1. Borzych-Duzalka D, Shroff R, Ariceta G, Yap YC, Paglialonga F, Xu H, Kang HG, Thumfart J, Aysun KB, Stefanidis CJ, Fila M, Sever L, Vondrak K, Szabo AJ, Szczepanska M, Ranchin B, Holtta T, Zaloszyc A, Bilge I, Warady BA, Schaefer F, Schmitt CP. Vascular access choice, complications, and outcomes in children on maintenance hemodialysis: findings from the International Pediatric Hemodialysis Network (IPHN) Registry. Am J Kidney Dis. 2019;74:193–202. doi: 10.1053/j.ajkd.2019.02.014. - DOI - PubMed
    1. North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) Annual dialysis report. Rockville: Emmes Corp; 2011.
    1. Hayes WN, Watson AR, Callaghan N, Wright E, Stefanidis CJ, European Pediatric Dialysis Working Group Vascular access: choice and complications in European paediatric haemodialysis units. Pediatr Nephrol. 2012;27:999–1004. doi: 10.1007/s00467-011-2079-3. - DOI - PubMed

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