A dedicated vascular access clinic for children on haemodialysis: Two years’ experience

Abstract

BackgroundArteriovenous fistula (AVF) formation for long-term haemodialysis in children is a niche discipline with little data for guidance. We developed a dedicated Vascular Access Clinic that is run jointly by a transplant surgeon, paediatric nephrologist, dialysis nurse and a clinical vascular scientist specialised in vascular sonography for the assessment and surveillance of AVFs. We report the experience and 2-year outcomes of this clinic.MethodsTwelve new AVFs were formed and 11 existing AVFs were followed up for 2 years. All children were assessed by clinical and ultrasound examination.ResultsDuring the study period 12 brachiocephalic, nine basilic vein transpositions and two radiocephalic AVFs were followed up. The median age (interquartile range) and weight of those children undergoing new AVF creation were 9.4 (interquartile 3–17) years and 26.9 (14–67) kg, respectively. Pre-operative ultrasound vascular mapping showed maximum median vein and artery diameters of 3.0 (2–5) and 2.7 (2.0–5.3) mm, respectively. Maturation scans 6 weeks after AVF formation showed a median flow of 1277 (432–2880) ml/min. Primary maturation rate was 83 % (10/12). Assisted maturation was 100 %, with two patients requiring a single angioplasty. For the 11 children with an existing AVF the maximum median vein diameter was 14.0 (8.0–26.0) mm, and the median flow rate was 1781 (800–2971) ml/min at a median of 153 weeks after AVF formation. Twenty-two AVFs were used successfully for dialysis, a median kt/V of 1.97 (1.8–2.9), and urea reduction ratio of 80.7 % (79.3–86 %) was observed. One child was transplanted before the AVF was used.ConclusionsA multidisciplinary vascular clinic incorporating ultrasound assessment is key to maintaining young children on chronic haemodialysis via an AVF.

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“…The observed high proportion of CVC as first vascular access (56%) in European practice is in contrast to recommendations in recent initiatives and guidelines, but in keeping with previous studies [10, 15, 16]. Some large US studies even reported a CVC usage of 80–90% in incident HD children [10, 17, 18].…”

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“…According to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines, the ideal vascular access is described as one which can deliver an adequate flow rate along with durability and a low complication rate. An arteriovenous fistula (AVF) is usually considered to be the best access for HD in adults and, as commented on by an emerging body of evidence, that it is the same also in children [12].…”

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“…With good play therapy and the use of local anaesthetic creams, fistulae can be successfully used even in very young children [17]. The development of a dedicated clinic with a multidisciplinary team of specialised ultrasonographers, a nephrologist, a senior haemodialysis nurse and a vascular surgeon has encouraged the use of arteriovenous (AV) fistulae and their maintenance after creation [18]. It has to be remembered that every patient has only five lifelines: two arms, two legs and the peritoneum.…”