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American Journal of Kidney Diseases

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

Published:April 19, 2019DOI:https://doi.org/10.1053/j.ajkd.2019.02.014

      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/Vurea 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.

      Index Words

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      Linked Article

      • Catheter Craze Continues for Pediatric Hemodialysis Vascular Access: The Need to Move From Catheter First to Catheter Last
        American Journal of Kidney DiseasesVol. 74Issue 2
        • Preview
          The establishment of a functional trouble-free vascular access continues to be the goal for patients with end-stage kidney disease (ESKD) who are hemodialysis (HD) dependent. Focused initiatives have been implemented in adults with an emphasis on central venous catheter (CVC) avoidance, with a move toward a higher arteriovenous fistula (AVF) placement rate.1,2 It is well known that AVFs are much more reliable than CVCs, with improved dialysis delivery (blood flow rate and Kt/Vurea) and fewer complications (need for access maintenance interventions and markedly lower infection rates).
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