Comparative efficacy of alteplase and urokinase in pharmacomechanical thrombolysis of permanent double lumen hemodialysis catheters in children

Background Thrombotic occlusion of permanent double lumen catheters (PDLC) in hemodialysis has traditionally been treated with urokinase (UK), a thrombolytic agent. However, because UK is no longer available, alteplase has been reported as an alternative. In this study, we compared the efficacy and safety of alteplase with those of UK. Methods This retrospective analysis included patients undergoing hemodialysis with thrombotic occlusion from May 2014 to February 2025. The drug was administered as a bolus dose into the catheter and allowed to dwell for 60 minutes. The primary endpoint was the blockage resolution rate after the first thrombolytic agent. Results During the study period, 24 patients underwent pharmacological thrombolysis, with a total of 165 procedures performed, including 37 with alteplase and 128 with UK. The median age and weight at the time of thrombotic occlusion were significantly lower in the alteplase group than in the UK group (1.7 vs. 3.9 years and 6.4 vs. 14.4 kg; p < 0.01). The alteplase group had a higher success rate (34/37, 94%) than the UK group (96/128, 75%) (p = 0.038). When the first dose of alteplase was unsuccessful, a second dose successfully cleared the blockage in all instances. No serious adverse effects, such as bleeding events, were observed in either group. Conclusions This study suggests the superiority of alteplase over UK in managing thrombotic occlusions of PDLCs. Moreover, alteplase appears to be safe for use in children weighing < 10 kg, with no serious adverse events observed.