Related Experiment Videos
Hemodialysis access in the pediatric patient population
A B Lumsden1, M J MacDonald, R C Allen
1Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Insights
Establishing hemodialysis access in children with chronic renal failure is challenging. Prioritizing distal, autogenous options maximizes access longevity and simplifies future interventions for pediatric patients.
Area of Science:
- Pediatric Nephrology
- Vascular Surgery
- Renal Replacement Therapy
Background:
- Chronic renal failure affects 3-5 children per million annually.
- A significant portion requires prolonged hemodialysis, presenting challenges in vascular access.
- Pediatric patients often have comorbidities impacting access options.
Purpose of the Study:
- To evaluate various hemodialysis access techniques in pediatric patients.
- To assess the patency rates and complications associated with different access modalities.
- To establish optimal strategies for pediatric hemodialysis access.
Main Methods:
- Retrospective review of 24 pediatric patients (1985-1992) requiring hemodialysis access.
- Analysis of arteriovenous fistulae, expanded polytetrafluoroethylene (ePTFE) bridge grafts, bovine grafts, and central venous catheters.
- Evaluation of functional patency, complications, and secondary patency after interventions.
Main Results:
- Overall mean functional patency across all procedures was 7.3 months.
- Autogenous fistulae had lower maturation rates, while ePTFE grafts showed variable patency.
- Complications included graft infections, venous occlusions, and limited success with certain prosthetic grafts.
Conclusions:
- Pediatric hemodialysis access is a complex and demanding clinical challenge.
- A philosophy of maximizing use from each access site is crucial.
- The "distal before proximal" and "autogenous before prosthetic" approach is recommended for pediatric hemodialysis access.
Background:
Each year, three to five children per million develop chronic renal failure. Of these, 70% will require dialysis for short periods, and 23% will require prolonged hemodialysis support. It is in the latter group that difficulty is encountered in establishing dialysis access.
Methods:
From 1985 to 1992, we provided hemodialysis access for a group of 24 children. There were 16 boys and 8 girls, with a mean age of 11.1 +/- 4 years (range 3 to 17). All children were significantly below the 50th percentile weight for their age and sex. Seven children entered hemodialysis following failed peritoneal dialysis after an average of 21 +/- 10.5 months. Seventeen patients received a renal transplant. Seven of these children have resumed hemodialysis.
Results:
The technique for establishing hemodialysis was varied: 15 arteriovenous fistulae, 37 expanded polytetrafluoroethylene (ePTFE) bridge grafts, 9 bovine arteriovenous bridge grafts, and 29 chronic central venous catheters. The overall mean functional patency of the fistulae was 6.2 +/- 10.2 months. One third of these fistulae failed to mature sufficiently to permit their use for dialysis purposes. Twenty-one upper extremity ePTFE grafts were implanted, with a mean functional patency of 11 +/- 11.1 months. Sixteen groin loop grafts were utilized, with a primary patency of only 4.1 +/- 5 months. Thrombectomy was performed in 25 cases (patch or interposition in 8 cases), with a secondary patency in these grafts of 10.5 +/- 17 months. An inability to achieve access in 2 children resulted in the creation of unusual types of access: an aorto-caval fistula and an axillo-femoral fistula and a combination of single-needle puncture of an immature fistula with one lumen of a PermCath. There were eight ePTFE graft infections, with graft loss occurring in seven cases. Superior vena caval occlusion occurred in two patients, inferior vena caval thrombosis in one patient, and axillo-subclavian venous occlusion in two patients. Development of central venous occlusions significantly increased the difficulty in establishing dialysis access. The total dialysis period provided by the 90 primary procedures performed in this study was 658 months. Each procedure, therefore, provided access for a mean duration of only 7.3 months.
Conclusion:
Providing dialysis access in the pediatric population is a time-consuming and frustrating challenge. We believe that all patients with renal dysfunction should have their conditions managed as potential long-term dialysis candidates. Therefore, our philosophy is to achieve maximal use from each access site. Although the primary patency of upper-arm ePTFE grafts was greater than that for the forearm fistulae in this study, failure of the upper-arm graft can result in loss of that limb for the purposes of future dialysis access. Consequently, we strongly advocate the "distal before proximal" and "autogenous before prosthetic" dogma in providing pediatric hemodialysis access.