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American Journal of Kidney Diseases

Catheter Craze Continues for Pediatric Hemodialysis Vascular Access: The Need to Move From Catheter First to Catheter Last

  • Rudolph P. Valentini
    Correspondence
    Address for Correspondence: Rudolph P. Valentini, MD, Pediatric Nephrology, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201-2119.
    Affiliations
    Group Chief Medical Officer: Michigan

    Pediatric Nephrology, Children's Hospital of Michigan, Detroit, MI

    Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
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  • Deepa H. Chand
    Affiliations
    Division of Pediatric Nephrology, Washington University School Of Medicine, St. Louis MO

    Pharmacovigilance and Patient Safety, R & D, AbbVie, North Chicago, IL
    Search for articles by this author
      Related Article, p. 193
      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.
      National Kidney Foundation
      K/DOQI clinical practice guidelines for vascular access: update 2000.
      National Kidney Foundation
      K/DOQI clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access.
      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).
      • Ravani P.
      • Palmer S.C.
      • Oliver M.J.
      • et al.
      Associations between hemodialysis access type and clinical outcomes: a systematic review.
      Although these differences have been illustrated repeatedly in larger studies dedicated to adult HD patients, there is a growing parallel body of evidence in the pediatric age group reflecting the same theme.
      • Ravani P.
      • Palmer S.C.
      • Oliver M.J.
      • et al.
      Associations between hemodialysis access type and clinical outcomes: a systematic review.
      • Chand D.H.
      • Brier M.
      • Strife C.F.
      Comparison of vascular access type in pediatric hemodialysis patients with respect to urea clearance, anemia management, and serum albumin concentration.
      • Baracco R.
      • Mattoo T.
      • Jain A.
      • Kapur G.
      • Valentini R.P.
      Reducing central venous catheters in chronic hemodialysis--a commitment to arteriovenous fistula creation in children.
      • Valentini R.P.
      • Geary D.F.
      • Chand D.H.
      Central venous lines for chronic hemodialysis: survey of the Midwest Pediatric Nephrology Consortium.
      Disappointingly, 2016 data from the United States found that pediatric HD patients initiate dialysis with a CVC >80% of the time, and an AVF is present either exclusively for use or developing with a CVC in situ in <17% of children.
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
      US trends in pediatric vascular access have shown minimal movement from 2006 to 2016: CVC use for HD initiation was 90% (77.7% CVC only and 12.3% CVC with maturing AVF) in 2006 and 91.8% (82.4% CVC only and 9.4% CVC with maturing AVF) in 2016.
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
      In this issue of AJKD, Borzych-Duzalka et al
      • Borzych-Duzalka D.
      • Shroff R.
      • Ariceta G.
      • et al.
      Vascular access choice, complications, and outcomes in children on maintenance hemodialysis: findings from the International Pediatric Hemodialysis Network (IPHN) registry.
      report findings from a 5-year prospective observational study from the International Pediatric Hemodialysis Network (IPHN) Registry. This monumental effort captures data from more than 550 children in 27 countries receiving maintenance HD and provides many insights into pediatric HD vascular access practices across the globe. The authors leveraged the power of the multicenter participation to capture practice patterns surrounding vascular access not seen before because most pediatric studies are center specific and typically with very small patient numbers. This undoubtedly makes this study the largest of its kind. Compared with US Renal Data System data, this large study reported a higher AVF use rate (26%) at dialysis initiation. Although encouraging, the CVC use rate at HD initiation was still 73%. Further analysis related to patient age showed that children older than 10 years, who should inherently have more favorable anatomy for an AVF or arteriovenous graft (AVG), started HD with a CVC 65% of the time. The CVC rate of 90% at HD initiation for children younger than 10 years indicates a strong CVC bias in younger children; one could speculate whether this is based on anatomic disadvantages with regard to the caliber of candidate veins and arteries for arteriovenous access surgery.
      Not unexpectedly, Borzych-Duzalka et al report complication rates that are much higher for CVCs when compared with AVFs, including infectious complications (absent in children dialyzed with an AVF), reduced measures of dialysis adequacy (Kt/Vurea), need for greater access maintenance and replacement procedures to restore blood flow necessary for HD, and higher erythropoietin resistance.
      • Borzych-Duzalka D.
      • Shroff R.
      • Ariceta G.
      • et al.
      Vascular access choice, complications, and outcomes in children on maintenance hemodialysis: findings from the International Pediatric Hemodialysis Network (IPHN) registry.
      While this aligns with data reported from smaller scale studies, the authors validate a universal theme: CVC use is associated with increased morbidity.
      The IPHN Registry study also illustrates the need for better access planning for pediatric patients with newly diagnosed kidney failure whose treatment modality will be HD. The fact that one-third of children who were dialyzed with an AVF required a CVC transiently until the AVF matured for use raises the question of how many of these CVCs could have been avoided altogether. Menon et al
      • Menon S.
      • Valentini R.P.
      • Kapur G.
      • Layfield S.
      • Mattoo T.K.
      Effectiveness of a multidisciplinary clinic in managing children with chronic kidney disease.
      reported the value of a chronic kidney disease (CKD) clinic for children with the focus on predialysis care: optimizing medical management of CKD and preemptive ESKD planning. In addition to improved medical management of CKD complications, the number of children who had an unscheduled dialysis initiation decreased from 50% to 10% and the successful use of an AVF/AVG at dialysis initiation increased from 20% to 86% when pre-ESKD care moved from a general nephrology clinic setting to a dedicated CKD clinic setting. This established multidisciplinary model featuring a pediatric nephrologist, clinical nurse coordinator, dietician, social worker, and both dialysis and transplantation coordinators provides continuity of care for pediatric patients with impending long-term renal replacement therapy needs, thereby providing a methodical approach to identify the right treatment option for each patient.
      Educating families as to the best available vascular access options for those seeking HD for renal replacement therapy is a huge advantage of a CKD clinic. The benefits and risks of each access type must be highlighted. Specifically, CVC risks relative to AVFs/AVGs include short-term risks: higher infection rates, hospitalizations, antibiotic exposures (some of which may be nephrotoxic, resulting in premature loss of residual renal function), and potentially delay in transplantation. Furthermore, long-term risks of CVCs include a high incidence of central venous stenosis and thrombosis, which can impede successful creation of an arteriovenous access (AVF/AVG) in the future.
      While CVC avoidance needs to be the goal, in the event that CVC placement cannot be avoided, it needs to be viewed by the family and medical team as a short-term bridge to a noncatheter vascular access. It is very important for families to recognize that ESKD is life long, and a patient undergoing successful kidney transplantation in early childhood is likely to need another form of renal replacement therapy sometime in the next 2 decades. Therefore, a child who develops central venous stenosis or thrombosis as a CVC complication will have limited vascular access options 10 to 20 years following transplantation in the event of allograft failure.
      • Woo K.
      • Lok C.E.
      New insights into dialysis vascular access: what is the optimal vascular access type and timing of access creation in CKD and dialysis patients?.
      It has been intimated that a scheduled transplantation is reason to forego consideration of an AVF/AVG.
      National Kidney Foundation
      K/DOQI clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access.
      However, in an evaluation of 1,284 pediatric patients receiving HD, of the nearly 60% of prevalent patients dialyzed with a CVC, Fadrowski et al
      • Fadrowski J.J.
      • Hwang W.
      • Neu A.M.
      • Fivush B.A.
      • Furth S.L.
      Patterns of use of vascular catheters for hemodialysis in children in the United States.
      found that just 10% had “transplant scheduled” as the reason given by their dialysis center for catheter placement. Further, only 69% of these patients underwent transplantation by 1 year (median, 115 days); thus, despite a “scheduled” transplantation, 31% did not undergo transplantation within a year. As such, these patients were exposed to the serious risks associated with use of a CVC, which are time dependent. The reliance on timely transplantation to justify the high rate of CVC use was also challenged by the authors of the IPHN Registry study, who found that those receiving HD with a CVC awaiting transplantation waited a median of 14 months, with one-quarter of patients remaining on dialysis therapy for more than 3 years.
      • Borzych-Duzalka D.
      • Shroff R.
      • Ariceta G.
      • et al.
      Vascular access choice, complications, and outcomes in children on maintenance hemodialysis: findings from the International Pediatric Hemodialysis Network (IPHN) registry.
      This speaks to the relative unpredictability of transplantation and the need to focus on expeditious catheter removal if one wants to minimize long-term risks of these devices and optimize dialysis treatment.
      Another surprising result was an apparent aversion to pursue an AVF/AVG altogether. Borzych-Duzalka et al reported that among children starting dialysis with a CVC, the conversion to AVF/AVG was woefully low and took inordinately long. No patients were dialyzed with an AVF/AVG at 6 months, and only 3%, within 18 months, with this value eventually reaching 27% within 36 months of starting HD.
      • Borzych-Duzalka D.
      • Shroff R.
      • Ariceta G.
      • et al.
      Vascular access choice, complications, and outcomes in children on maintenance hemodialysis: findings from the International Pediatric Hemodialysis Network (IPHN) registry.
      These low conversion rates highlight an apparent lack of urgency or effectiveness in disassociating the pediatric HD patient from the CVC for HD vascular access. Perhaps when a CVC is placed, its removal may be deemed unnecessary or inconvenient.
      Clearly, commitment to AVF/AVG placement for the pediatric HD patient requires planning and a coordinated approach with referral to a vascular access surgeon with competence and confidence to confront the surgical challenges in the smaller patient. The dialysis director is critical for establishing the culture of minimizing catheter use. This starts with a partnership with the CKD clinic leader to aim for catheter avoidance for elective dialysis patients by incorporating vascular access decision making into the care algorithm for care of the pediatric patient when estimated glomerular filtration rate is <30 mL/min/1.73 m2. Dedicated pediatric vascular access coordinators appear to be effective to not only increase AVF creation, but also monitor their maturation to ensure timely use of AVFs. This is another strategy to minimize CVC exposure for those starting HD with a CVC with subsequent AVF creation, thus facilitating transition to an optimal vascular access option.
      • Shroff R.
      • Sterenborg R.B.
      • Kuchta A.
      • et al.
      A dedicated vascular access clinic for children on haemodialysis: two years' experience.
      • Bagolan P.
      • Spagnoli A.
      • Ciprandi G.
      • et al.
      A ten-year experience of Brescia-Cimino arteriovenous fistula in children: technical evolution and refinements.
      A coordinator can provide continuum of care among nephrologists, nurses, access surgeons, radiologists, and interventionalists.
      Patients with newly diagnosed kidney failure pose a challenge to catheter avoidance because patients requiring urgent HD will necessitate CVC placement and use. However, many pediatric patients with new-onset kidney failure may be good candidates for peritoneal dialysis (PD), which should be considered at the outset. As such, if able to make a timely assessment of the skill set and commitment of the family to home PD, the only “catheter” this pediatric patient may require is a PD catheter, thereby avoiding even a temporary CVC for a few HD sessions. To achieve acute PD for appropriate candidates, the pediatric nephrology service has to be committed to this initiative, and in so doing, partner with intensivists to consult nephrology for renal replacement therapy recommendations before placing a CVC.
      In summary, Borzych-Duzalka et al have appropriately highlighted the negative consequences of CVC use as compared with AVFs. Although this is well-established knowledge in the pediatric nephrology community, there have been no major advances in pediatric vascular access for children. This is surprising despite successful approaches to improve vascular access care coordination and the use of operating microscopes to enhance surgical placement in small children.
      • Menon S.
      • Valentini R.P.
      • Kapur G.
      • Layfield S.
      • Mattoo T.K.
      Effectiveness of a multidisciplinary clinic in managing children with chronic kidney disease.
      • Fadrowski J.J.
      • Hwang W.
      • Neu A.M.
      • Fivush B.A.
      • Furth S.L.
      Patterns of use of vascular catheters for hemodialysis in children in the United States.
      • Bagolan P.
      • Spagnoli A.
      • Ciprandi G.
      • et al.
      A ten-year experience of Brescia-Cimino arteriovenous fistula in children: technical evolution and refinements.
      • Bourquelot P.
      • Raynaud F.
      • Pirozzi N.
      Microsurgery in children for creation of arteriovenous fistulas in renal and non-renal disease.
      • Chand D.H.
      • Bednarz D.
      • Eagleton M.
      • Krajewski L.
      A vascular access team can increase AV fistula creation in pediatric ESRD patients: a single center experience.
      Practitioners should advocate for the long-term decrease in morbidity and mortality by taking proper actions to move from a Catheter First to Catheter Last approach for our patients as we help coordinate their ESKD life plan.
      • Woo K.
      • Lok C.E.
      New insights into dialysis vascular access: what is the optimal vascular access type and timing of access creation in CKD and dialysis patients?.

      Article Information

      Authors’ Full Names and Academic Degrees

      Rudolph P. Valentini, MD, and Deepa H. Chand, MD, MHSA.

      Support

      None.

      Financial Disclosure

      Dr Chand is an employee and shareholder of Abbvie, Inc. Dr Valentini declares that he has no relevant financial interests.

      Peer Review

      Received March 27, 2019, in response to an invitation from the journal. Direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form April 22, 2019.

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