Vascular Access Choice, Complications, and Outcomes in Children on Maintenance Hemodialysis: Findings From the International Pediatric Hemodialysis Network (IPHN) Registry

doi:10.1053/j.ajkd.2019.02.014

American Journal of Kidney Diseases

Volume 74, Issue 2, August 2019, Pages 193-202

https://doi.org/10.1053/j.ajkd.2019.02.014 Get rights and content

Rationale & Objective

Arteriovenous fistulas (AVFs) have been recommended as the preferred vascular access for pediatric patients on maintenance hemodialysis (HD), but data comparing AVFs with other access types are scant. We studied vascular access choice, placement, complications, and outcomes in children.

Study Design

Prospective observational cohort study.

Setting & Participants

552 children and adolescents from 27 countries on maintenance HD followed up prospectively by the International Pediatric HD Network (IPHN) Registry between 2012 and 2017.

Predictor

Type of vascular access: AVF, central venous catheter (CVC), or arteriovenous graft.

Outcome

Infectious and noninfectious vascular access complication rates, dialysis performance, biochemical and hematologic parameters, and clinical outcomes.

Analytical Approach

Univariate and multivariable linear mixed models, generalized linear mixed models, and proportional hazards models; cumulative incidence functions.

Results

During 314 cumulative patient-years, 628 CVCs, 225 AVFs, and 17 arteriovenous grafts were placed. One-third of the children with an AVF required a temporary CVC until fistula maturation. Vascular access choice was associated with age and expectations for early transplantation. There was a 3-fold higher living related transplantation rate and lower median time to transplantation of 14 (IQR, 6-23) versus 20 (IQR, 14-36) months with CVCs compared with AVFs. Higher blood flow rates and Kt/V_urea were achieved with AVFs than with CVCs. Infectious complications were reported only with CVCs (1.3/1,000 catheter-days) and required vascular access replacement in 47%. CVC dysfunction rates were 2.5/1,000 catheter-days compared to 1.2/1,000 fistula-days. CVCs required 82% more revisions and almost 3-fold more vascular access replacements to a different site than AVFs (P < 0.001).

Limitations

Clinical rather than population-based data.

Conclusions

CVCs are the predominant vascular access choice in children receiving HD within the IPHN. Age-related anatomical limitations and expected early living related transplantation were associated with CVC use. CVCs were associated with poorer dialysis efficacy, higher complication rates, and more frequent need for vascular access replacement. Such findings call for a re-evaluation of pediatric CVC use and practices.

Section snippets

Data Collection

The IPHN collects detailed prospective information on incident and prevalent maintenance HD patients treated in pediatric dialysis units around the globe. At the time of enrollment, basic patient demographic data and information regarding access placement are captured. All vascular access revisions/replacements are documented on occurrence. The vascular access intervention history for prevalent patients is entered retrospectively. Follow-up data (updates) are collected every 6 months following

Demographics

A total of 552 maintenance HD patients (56% males) treated at 55 pediatric dialysis units in 27 countries were entered into the IPHN database between December 2012 and September 2017. There were 313 patients (57%) followed up from HD initiation, while 249 patients (43%) were prevalent on HD at the time of enrollment. There were 282 patients (51%) from Western Europe, 63 (11%) from Central Europe, 80 (15%) from Asia, 68 (12%) from Turkey, 27 (5%) from North America, 19 (3.5%) from the Middle

Discussion

Data pertaining to vascular access in pediatric HD are limited because of the small number of patients that are cared for in individual sites. Here, we have used the strength of the multicenter nature of the IPHN to provide the largest pediatric HD study to date on vascular access choice, efficacy, and outcome.

Only one-quarter of the 404 children initiating HD received an AVF as initial access, with 73% receiving a CVC, and 1%, an AVG. Although the preference for a CVC in the pediatric

Article Information

Authors’ Full Names and Academic Degrees

Dagmara Borzych-Duzalka, MD, Rukshana Shroff, MD, Gema Ariceta, MD, Yok-Chin Yap, MD, Fabio Paglialonga, MD, Hong Xu, MD, Hee Gyung Kang, MD, Julia Thumfart, MD, Karabay Bayazit Aysun, MD, Constantinos J. Stefanidis, MD, Marc Fila, MD, Lale Sever, MD, Karel Vondrak, MD, Attila J. Szabo, MD, Maria Szczepanska, MD, Bruno Ranchin, MD, Tuula Holtta, MD, Ariane Zaloszyc, MD, Ilmay Bilge, MD, Bradley A. Warady, MD, Franz Schaefer, MD, and Claus Peter Schmitt, MD.

Authors’ Contributions

Research idea and study design: DB-D,

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End-stage renal disease (ESRD) in childhood and adolescence is rare, with relatively few published reports of pediatric ESRD vascular access. This study analyzes a 10-year experience creating arteriovenous fistulas (AVFs) in children and adolescents. Our goal is to review our strategy for creating functional autogenous vascular access in younger patients and report our results.
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Thirty-seven AVFs were created in 35 patients. No grafts were used. Ages were 6 to 19 years (mean, 15 years), and 20 were male. Causes of ESRD included glomerular disease (n = 18) and urinary obstruction or reflux (n = 7), among others. Three had previous AVFs, and 10 were obese. The proximal radial artery supplied AVF inflow in 25 patients and the brachial artery in only seven. Eleven individuals required a transposition and one a vein translocation to the contralateral arm. No patients developed hand ischemia, although two later required banding procedures for high flow. Eleven patients had successful transplants. A single patient died, unrelated to the vascular access. Five AVFs failed. Of these, two had new successful AVFs created, two regained renal function, one was transplanted, and one declined other procedures. Primary and cumulative patency rates were 75% and 85% at 12 months, 70% and 85% at 24 months, and 51% and 85% at 36 months, respectively. Median follow-up was 16 months.
Creating an AVF for hemodialysis is a successful vascular access strategy for pediatric and adolescent patients. Proximal radial artery AVFs provided safe and functional access when a distal AVF was not feasible. Cumulative AVF patency was 85% at 36 months.
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AVF is being increasingly used as the modality of choice for maintenance hemodialysis especially in older children. Data from large pediatric registries show that an AVF is chosen as the first access in less than 50% of children being initiated on hemodialysis.5,13 In some cases, especially in younger children, a CVC may be the preferred access.
Arteriovenous fistula (AVF) is the recommended access of choice in children on maintenance hemodialysis. The challenges of creating and maintaining a fistula in children are many. The objective of our study was to describe the clinical profile and outcomes of AVFs in children from a resource-limited setting.
A retrospective analysis of children who have had an AVF for maintenance hemodialysis from 2010 to 2020 was performed. The center protocol for creation and management of complications was followed. Failure of fistula to mature was defined as primary failure. Primary patency was defined as the time from creation of access to the first complication requiring intervention. The primary failure rate, duration of primary patency and associated risk factors, and 1- and 3-year primary fistula patency rates were studied.
Thirty-six children (38 AVFs) with the median (interquartile range) age of 11 (8, 13) years were included. Brachiocephalic anastomosis was the most common site (75%) of AVF. The primary failure rate was 5.5% (2 of 36). The mean (95% confidence interval) duration of primary patency was 42.3 (29.9, 54.7) months. There were no particular factors associated with the duration of primary patency. The 1- and 3-year primary patency rate was 91% and 73%, respectively.
In resource-limited settings, AVF had good primary patency and is a feasible and durable access for maintenance hemodialysis in children.
Epidemiology and Risk Factors for Hemodialysis Access–Associated Infections in Children: A Prospective Cohort Study From the SCOPE Collaborative
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Similar to prior studies, we found that catheters were more commonly used and were associated with higher rates of infection compared with AV accesses.1,3,15-17 Despite international consensus guidelines supporting the use of AV accesses in children receiving HD, catheters remain the most commonly used form of HD access in children worldwide.4-7,18,19 Reasons for catheter use in children include small vasculature or kidney transplant expected to occur within a short period after dialysis initiation.7,9,20
Infections cause significant morbidity and mortality for children receiving maintenance hemodialysis (HD). The Standardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a quality-improvement initiative aimed at reducing dialysis-associated infections by implementing standardized care practices. This study describes patient-level risk factors for catheter-associated bloodstream infections (CA-BSIs) and examines the association between dialysis center–level compliance with standardized practices and risk of CA-BSI.
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Children enrolled in SCOPE between June 2013 and July 2019.
Data were collected on patient characteristics and center-level compliance with HD catheter care practices across the study period. Centers were categorized as consistent, dynamic (improved compliance over the study period), or inconsistent performers based on frequency of compliance audit submission and changes in compliance with HD care practices over time.
CA-BSIs.
Generalized linear mixed models were used to evaluate (1) patient-level risk factors for CA-BSI and (2) associations between change in center-level compliance and CA-BSIs.
The cohort included 1,277 children from 35 pediatric dialysis centers; 1,018 (79.7%) had a catheter and 259 (20.3%) had an arteriovenous fistula or graft. Among children with a catheter, mupirocin use at the catheter exit site was associated with an increased rate of CA-BSIs (rate ratio [RR], 4.45; P = 0.004); the use of no antibiotic agent at the catheter exit site was a risk factor of borderline statistical significance (RR, 1.79; P = 0.05). Overall median compliance with HD catheter care practices was 87.5% (IQR, 77.3%-94.0%). Dynamic performing centers showed a significant decrease in CA-BSI rates over time (from 2.71 to 0.71 per 100 patient-months; RR, 0.98; P < 0.001), whereas no significant change in CA-BSI rates was detected among consistent or inconsistent performers.
Lack of data on adherence to HD care practices on the individual patient level.
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Renal replacement therapy for children with end-stage renal disease consists of kidney transplantation or dialysis. Dialysis is often required at the outset of diagnosis due to urgent start need in many cases and inadequate organ supply in others. Both hemodialysis and peritoneal dialysis (PD) are relied upon as lifesaving modalities with the ultimate goal of reaching renal transplantation. Hemodialysis requires successful attainment of vascular access, which can be accomplished by placement of an arteriovenous fistula (AVF), arteriovenous graft (AVG), or central venous catheter (CVC). The pros and cons of each vascular access strategy are discussed, with the emphasis on avoiding CVCs due to morbidity of increased bloodstream infections, increased hospitalizations, need for frequent revisions, along with long-term complications such as central venous stenosis and thrombosis, which make placement of successful AVF or AVG more difficult. Strategies to increase AVF and AVG are discussed. PD is the most common modality for children 9 years old or younger. PD requires surgical placement of a PD catheter. Successful PD catheter placement begins with proper patient selection, followed by timely surgical consultation and preoperative patient preparation. Next, intraoperative approaches, including partial omentectomy and pelvic catheter location followed by postoperative tactics, are discussed with the focus on optimizing successful PD catheter placement with minimal complications. The hope is that the reader will gain a better understanding of strategies to secure an optimal dialysis access for the child requiring either hemodialysis or PD.
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The most common interventions were surgical thrombectomy, followed by balloon angioplasty and surgical revision. The IPHN review of 17 AVGs reported 1.9 malfunctions/1,000 graft days.73 In 1990, Cinat et al reported results of a prospective, multicenter study of 86 AVGs.162
Pediatric hemodialysis access is a demanding field. Procedures are infrequent, technically challenging, and associated with high complication and failure rates. Each procedure affects subsequent access and transplants sites. The choice is made easier and outcomes improved when access decisions are made by a multidisciplinary, pediatric, hemodialysis access team. This manuscript reviews the current literature and offers technical suggestions to improve outcomes.

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Original InvestigationVascular Access Choice, Complications, and Outcomes in Children on Maintenance Hemodialysis: Findings From the International Pediatric Hemodialysis Network (IPHN) Registry

Rationale & Objective

Study Design

Setting & Participants

Predictor

Outcome

Analytical Approach

Results

Limitations

Conclusions

Section snippets

Data Collection

Demographics

Discussion

Article Information

Authors’ Full Names and Academic Degrees

Authors’ Contributions

Kidney Int

Am J Kidney Dis

J Vasc Surg

J Pediatr Surg

J Vasc Surg

Am J Transplant

Kidney Int

Am J Kidney Dis

Am J Transplant

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Clinical practice recommendation 8: vascular access in pediatric patients

Am J Kidney Dis

North American Pediatric Renal Trials and Collaborative Studies Annual Dialysis Report

on behalf of the European Pediatric Dialysis Working Group. Hemodialysis in children: general practical guidelines

Pediatr Nephrol

European Paediatric Dialysis Working Group. Factors influencing choice of renal replacement therapy in European paediatric nephrology units

Pediatr Nephrol

A comparison of arteriovenous fistulas and central venous lines for long-term chronic haemodialysis

Pediatr Nephrol

Original Investigation
Vascular Access Choice, Complications, and Outcomes in Children on Maintenance Hemodialysis: Findings From the International Pediatric Hemodialysis Network (IPHN) Registry