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Reducing central venous catheters in chronic hemodialysis--a commitment to arteriovenous fistula creation in children
Rossana Baracco1, Tej Mattoo, Amrish Jain
1Department of Pediatrics, Division of Pediatric Nephrology, Children's Hospital of Michigan/Wayne State University, 3901 Beaubien St, Detroit, MI, 48201, USA.
Insights
Increasing arteriovenous fistula (AVF) use in pediatric hemodialysis patients, through a dedicated approach, significantly reduced central venous catheter (CVC) use and lowered infection and hospitalization rates.
Area of Science:
- Pediatric Nephrology
- Vascular Surgery
- Dialysis Access
Background:
- Central venous catheters (CVC) are common in pediatric hemodialysis, despite internal permanent vascular access (arteriovenous fistula/graft - AVF/AVG) preference.
- This study evaluates the experience with AVF in children undergoing chronic hemodialysis.
Purpose of the Study:
- To assess the feasibility and outcomes of increasing AVF utilization in pediatric hemodialysis patients.
- To compare AVF outcomes with CVC use regarding infection and hospitalization rates.
Main Methods:
- Retrospective chart review of pediatric patients (1-18 years) on chronic hemodialysis from 2001-2012.
- Patients divided into three time periods to evaluate changes in AVF placement and use strategies.
- Inclusion of a vascular surgeon for complex AVF candidates starting in 2010.
Main Results:
- Sixty-five AVFs were created in 55 patients; successful AVF use increased from 52.6% to 92.3% over the study period.
- AVF use rose, while CVC use decreased significantly, reaching 7.7% by 2012.
- AVF demonstrated lower infection (0.1 vs. 0.8 per access-year) and hospitalization (0.2 vs. 0.9 per access-year) rates compared to CVC (p<0.001).
Conclusions:
- A dedicated vascular access team and strategic approach can successfully increase AVF use in pediatric hemodialysis.
- Higher AVF utilization is associated with reduced access-related complications, including infections and hospitalizations.
Background:
An internal permanent vascular access [arteriovenous fistula (AVF) or arteriovenous graft (AVG)] is preferred over central venous catheters (CVC) for chronic hemodialysis. However, CVC remain the most commonly used access in children. The objective of this study was to evaluate our experience with AVF.
Methods:
We conducted a retrospective chart review of children aged 1-18 years on chronic hemodialysis from 2001 to 2012. Patients were divided into three time periods: 2001-2005, 2006-2009 and 2010-2012. A systematic approach to AVF placement was introduced in our department in 2006 which resulted in a greater number of AVF being placed and used, but the access failure rate was still higher than desired. In 2010, a more experienced vascular surgeon was contacted to perform AVF surgery in our most difficult AVF candidates.
Results:
Sixty-five AVF were created in 55 patients (67.3 % male). The median age of the patients was 14 (3-18) years. Forty-one (63.1 %) AVF were used successfully, and this number increased from 52.6 to 57.6 to 92.3 % over the three time periods, respectively. Over time, AVF use rates increased and CVC use decreased. By 2012 only 7.7 % of our patients were using a CVC. The primary patency rate was 42.9 % at 1 year; secondary patency rates were 100 and 93.8 % at 1 and 2 years, respectively. Infection and hospitalization rates were higher for CVC than for AVF [0.8 vs. 0.1 infections per access-year (p < 0.001) and 0.9 vs. 0.2 hospitalizations per access-year (p < 0.001)].
Conclusions:
With a dedicated approach and vascular access team it is possible to decrease CVC and increase AVF use in children on hemodialysis. In our study, increased AVF use resulted in decreased access-related infection and hospitalization rates.
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