Pediatric Hemodialysis Access
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- Millicent Maxwell
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1 Pediatric Hemodialysis Access Vincent L. Rowe, M.D., FACS Professor of Surgery Division of Vascular Surgery Keck School of Medicine at University of Southern California
2 NO FINANCIAL DISCLOSURES
3 Outline Patient characteristics Hemoaccess Fistulas Catheters Technical differences Barriers to fistula placement
4 Data North American Pediatric Renal Trial and Collaborative Study 2011 Annual Report (NAPRTCS) Over 7000 Pediatric dialysis patients 2012 and 2011 United States Renal Data System CMS, UNOS, other ESRD databases
5 Introduction 3-5 children per million develop chronic renal failure annually Of these, 70% will require dialysis for short periods 23% will require prolonged hemodialysis support
6 Incident & prevalent counts & adjusted rates in the pediatric ESRD population, by primary diagnosis USRDS 2011 ESRD patients age Adj: age/gender/race; ref: 2005 ESRD patients.
7 NAPRTCS 2012
8 NAPRTCS 2012
9 Incidence ESRD by Diagnosis USRDS 2012 Incident ESRD patients age 0 19; unadjusted
10 Incidence ESRD by Gender USRDS 2012 Incident ESRD patients age 0 19; unadjusted
11 Incidence ESRD by Race USRDS 2012 Incident ESRD patients age 0 19; unadjusted
12 Incidence ESRD by Modality USRDS 2012 Incident ESRD patients age 0 19; unadjusted
13 Incidence ESRD by Age USRDS 2012 Incident ESRD patients age 0 19; unadjusted
14 NAPRTCS 2012
15 One-year adjusted all-cause mortality rates in pediatric patients (from day one), by age & modality USRDS 2012
16 Adjusted five-year survival in pediatric patients (from day one), by age & modality,
17 NAPRTCS 2012
18 NAPRTCS 2012
19 One-year adjusted rates of mortality due to infection in pediatric patients (from day one), by age & modality USRDS 2012
20 One-year adjusted cardiovascular mortality rates in pediatric patients (from day one), by age & modality USRDS 2012
21 NAPRTCS 2012
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32 Hemodialysis access in the pediatric patient population. Am J Surg Aug;168(2): patients (mean age 11.1) 15 AVF, 37 AVG, 9 bovine, 29 CVC Functional patency: AVF: 6.2 mo. AVG (Upper arm): 11.1 mo. Distal forearm first approach recommended
33 Experience with autogenous arteriovenous access for hemodialysis in children and adolescents. Ann Vasc Surg Sep;19(5): patients (mean age 14.6) All vein mapped Cimino: 16, BCF: 15, BVT: 7, FemV: 9 3 with microscope Primary 1 and 2 yrs: 100% and 96%
34 Two-stage basilic vein transposition- a new approach for pediatric dialysis access. J Pediatr Surg Jan;45(1): AV access AV access procedures 15 two-stage BVT Improved maturation, usage and primary patency
35 Pediatric Dialysis USC patients with 101 fistulas Average age 14.3 (3-19) 82% on dialysis at time of fistula Time to transplant 556 days
36 100% Primary Patency 80% 60% Increased age correlated with Improved 1 patentcy p % 20% 0% Days
37 100% Secondary Patency 80% 60% 40% 20% 0% Days
38 Technical Differences Vasospasm Pre and Intraoperative vein mapping Tourniquet occlusion Microscope Greater saphenous Femoral vein well tolerated Avoidance of prosthetic grafts
39
40 NAPRTCS 2012
41 NAPRTCS 2012
42 NAPRTCS 2012
43 NAPRTCS 2012
44 NAPRTCS 2012
45
46 Pediatric Catheters No Pre-Curve
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48 Pediatric Catheters No Pre-Curve Few catheter lengths Micro-puncture kit Ultrasound guidance Wire in IVC French size to age match equation (±)
49 Vascular access: choice and complications in European paediatric haemodialysis units. Pediatr Nephrol Jun;27(6): Survey from 13 pediatric dialysis units (111 patients) 60% central venous catheters Type of access related to age Median age: 12: CVC, 16: AVF/AVG (p<0.001) Higher infection rates with CVC
50 Hemodialysis vascular access options in pediatrics: considerations for patients and practitioners. Pediatr Nephrol Jun;24(6): Despite a national initiative for fistula first in the adult hemodialysis population, the pediatric nephrology community in the United States of America utilizes central venous catheters as the primary dialysis access for most patients. Vascular access management requires proper advance planning, seamless communication involving multidisciplinary team of nephrologists, nurses, surgeons, and interventional radiologists... It is imperative that practitioners have a long-term vision to decrease morbidity in this unique patient population.
51 Hemodialysis vascular access options in pediatrics: considerations for patients and practitioners. Pediatr Nephrol Jun;24(6): Despite a national initiative for fistula first in the adult hemodialysis population, the pediatric nephrology community in the United States of America utilizes central venous catheters as the primary dialysis access for most patients. Vascular access management requires proper advance planning, seamless communication involving multidisciplinary team of nephrologists, nurses, surgeons, and interventional radiologists... It is imperative that practitioners have a long-term vision to decrease morbidity in this unique patient population.
52 Access Evaluation - Patient Concerns I m afraid of needles I won t be able to wear jewelry I won t be able to play sports Fistulas look ugly I don t want anyone to see it on my arm
53
54 Access Evaluation Parent Concerns I m not sure what is best for him/her He/she doesn t like needles A family member is being evaluated to donate a kidney
55 Study Survey to all hemodialysis pediatric patients at CHLA Survey questions specific to type of access being used Parents
56 Objective To determine if psychosocial factors impact the type of access chosen by pediatric patients
57 Have you had other AV fistulas/grafts before? No Yes Don t know If yes, where and when was it placed? Year: Location: Are you happy with your current access type? No Yes Don t know Do you think fistulas/grafts look ugly? No Yes Don t know Did your doctor or nurse ever tell you that an AV fistula/graft is better for your health than a catheter? No Yes Don t know Did you choose to have a catheter instead of a fistula/graft? No Yes Don t know If you had a fistula/graft, would you be afraid of what people would say or think if they saw it? No Yes Don t know Are you worried that you wouldn t be able to wear jewelry or accessories around your fistula/graft? No Yes Don t know Are you afraid of having surgery to make the fistula/graft? No Yes Don t know Are you afraid of being stuck with needles for dialysis if you had a fistula/graft? No Yes Don t know Are you worried that you won t be able to play sports or do other activities if you had a fistula/graft?
58 Results 25 pediatric patients 23 patient surveys collected 10 parent surveys collected Patient access type and age No AVG AVF CVC P N 10 (43%) 13 (57%) Mean age <0.01
59 100% 90% 80% 70% 60% 50% Results 60% 60% 54% 54% 46% 69% 70% CVC AVF 60% 54% 40% 30% 20% 20% 10% 0%
60 Results 70% of patients in AVF group were satisfied with their access 20% embarrassed about fistula 40% hide fistula with clothing 20% would revert to CVC for hemodialysis
61 Results - Parents Nine (90%) parents reported being told by healthcare professional that an AVF is better, 40% parents believed an AVF was better for their child 50% said decision was shared with child
62 Summary Psychosocial barriers persist in the transition of CVC patients to AVFs Both groups shared similar concerns regarding AVFs Majority of AVF patients remain satisfied with their type of access Findings related to age, maturity, acceptance
63 Clinical Recommendation Patients 13 Time to transplantation Psychological factors Patency Internal Jugular vein Not as aggressive with fistula first Catheter based hemodialysis Patients 13
64 Clinical Recommendation Patients 13 Time to transplantation Psychological factors Patency Internal Jugular Not as aggressive with fistula first Catheter based hemodialysis Patients 13 Time to transplantation longer (especially 18 or older) Some failed transplant Psychological factors Acceptance Improved patency Fistula First
65 Conclusion Implementation of fistula first approach remains difficult in pediatric population with multiple factors to consider Patient and parent education imperative to improve outcomes and decrease catheter usage
66 Thank You
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