Iatrogenic Liver Dysfunction secondary to a Haemodialysis Catheter
Y. Aggarwal MRCP MA, Specialist Registrar
Introduction: 200,000 central venous catheters are inserted each year for various indications including:
• Infusion of Drugs
• Parental Nutrition
• Renal Replacement Therapy
Common complications include infection, bleeding, line related thrombosis and line dysfunction. We present a lesser known complication of catheter tip misplacement resulting in an acute mechanical Budd-Chiari syndrome. Line replacement led to full recovery of the patient.
The Case: A 35 year old female presented with a few weeks history of :
- Abdominal Cramps
She had a background of IgA nephropathy and was on haemodialysis three times a week following two failed renal transplants.
Due to renal stones and related episodes of sepsis, the patient went on to have bilateral nephrectomies in 2012. As a result her ‘normal’ blood pressure was 70/40mmHg and had facilitated the loss of multiple arteriovenous fistulae. She was awaiting a biologic arteriovenous graft formation, and in the interim, dialysed through a 28cm 14Fr right jugular tunnelled central venous catheter which had been placed in February 2013. The line was placed under fluoroscopic radiological guidance and both catheter tips were seen in the right atrium on a CXR post procedure.
Dialysis sessions were meeting dialysis adequacies and clearances.
Examination: The patient was haemodynamically stable and there were no focal abnormalities of note. She did complain of some mild pain over the right upper quadrant on deep palpation.
Blood results (SI units):
- Hb 10.6 WCC 7.5 Platelets 150
- Na 139 K+ 4.8 Urea 11 Creat 212 (pre-HD)
- C-RP 25
- Bil 11 ALT 370** Alk.phos 210** ALB 29
- GGT 400** **acute rise in ALP/ALT compared to 'monthly' dialysis bloods
Initial investigations revealed the patient had a FBC and UE as expected for a patient on dialysis. The CRP was mildly elevated and the liver function tests were deranged suggesting a hepatitic picture.
• Blood cultures were negative.
• The blood borne virus screen and toxicology screens were negative/normal.
• There had been no history of new medications or recent travel.
• She had been well prior to her presentation.
• Ultrasound abdomen showed minimal drainage and reversed flow in the main portion of the portal vein with evidence of collaterals entering the porta hepatis and even early recannalisation of the umbilical vein. There was also poor drainage in the right hepatic vein but with normal flow. The other hepatic veins and the hepatic artery were patent. No thrombi were seen. The hepatic duct was not dilated.
• A contrast CT abdomen showed that the liver generally appeared to look abnormal and appearances indicated an acute hepatitis. No areas of infarction or distinct lesions were seen. The portal vein, hepatic artery and hepatic veins were patent with no evidence of thrombosis. The central line passed through the right atrium with 1 limb in the right hepatic vein, and likely to be resulting in some impaired venous drainage from the liver. The spleen and gall bladder were normal. Some free fluid was also noted within the abdominal cavity.
The CT images below demonstrate the tunnelled line leaving the right atrium and travelling down the IVC. One lumen terminates within the IVC, and the other terminates within the hepatic vein resulting in partial obstruction to flow (Fig. 1-3).
Figures 1, 2 and 3.
The patient proceeded to have the tunnelled line exchanged. A pre-exchange linogram demonstrates the malposition of the tunnelled line tip clearly (Fig. 4). Figure 5, is the chest x-ray showing the positioning of the new tunnelled line, which the patient was able to use immediately.
After the line exchange, the patient clinically and biochemically improved to her baseline state. She was discharged within 48 hours. She did not require any antibiotics.
On review of the patient's past imaging, the migration of the line over a period of 12 months was evident on serial chest x-rays although very difficult to see. The patient’s admission chest x-ray is in figure 6.
Discussion: Tunnelled venous catheters are not gold standard access for haemodialysis, and are generally used when arteriovenous access has failed or where the risks of preforming arteriovenous access surgery are likely to cause the patient harm or when a patient has rapidly progressed to requiring haemodialysis. Tunnelled lines are ideally, but not routinely, placed under fluoroscopic guidance to avoid the risks of line malposition and dysfunction.
Insertion of an internal jugular vein catheter is associated with a reduced rate of malpositioning versus subclavian venous catheters. There is an increased risk of catheter migration associated with body habitus, general movement and catheter site/insertion.
Migration of the catheter tip into the hepatic vein can cause an acute Budd-Chiari syndrome but this is rarely seen and has never previously been reported where the outcome was benign. This patient had acute Budd-Chiari (BC) secondary to hepatic venous outflow obstruction from the dialysis catheter tip. The condition is usually characterized by rapid development of abdominal pain, ascites, hepatomegaly, jaundice, and renal failure. Some of the fluid shifts resulting in extracellular fluid collections may not be as apparent due to fluid removal on haemodialysis.
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