Hemodialysis access: guidelines, evidence and controversies

Marc R Lilien, MD, PhD

Pediatric nephrologist

Current guidelines on vascular access

- European Best Practice Guidelines on Vascular Access

Nephrol.Dial.Transplant. 2007; (22) [Suppl 2]: ii88-ii117

- NKF K/DOQI guidelines: Clinical Practice Guidelines and Clinical

Practice Recommendations, 2006 updates: Vascular Access

Clinical Practice Recommendation 8: Vascular Access in Pediatric

Patients

http://www.kidney.org/professionals/kdoqi/guideline_upHD_PD_VA/va_rec8.htm

8.1 Choice of access type

- 8.1.1 Permanent access in the form of a fistula or graft is the

preferred form of vascular access for most pediatric patients on

maintenance HD therapy

- 8.1.2 Circumstances in which a CVC may be acceptable

- Lack of local surgical expertise

- Patient size too small

- Temporary access (bridging to PD, expeditious Tx)

- 8.1.3 Lack of surgical expertise in the pediatric setting

- 8.1.4 Permanent vascular access in children > 20 kg, who are

expected to wait > 1 year for a kidney transplant

8.1.1 Permanent access in the form of a fistula or graft: preservation is the key

- Early education of CRF patients

- Preferential venipuncture from and i.v. lines in the dorsal hand

veins

- preoperative Duplex ultrasound examination of upper extremity

arteries and veins

- Central vein evaluation in appropriate patients known to have a

previous catheter

8.1.1 Permanent access in the form of a fistula or graft?

8.1.1 Permanent access in the form of a fistula or graft?

8.1.1 Permanent access in the form of a fistula or graft?

8.1.1 Permanent access in the form of a fistula or graft?

8.1.1 Permanent access in the form of a fistula or graft

8.1.1 Permanent access in the form of a fistula or graft

8.1.1 Permanent access in the form of a fistula or graft

8.1.1 Permanent access in the form of a fistula or graft?

- CVC survival is poor: 1 year secondary patency rate 30%-60%

- CVC insertion is associated with central venous stenosis,

jeopardizing future creation of AVF

- AVF and AVG half life in pediatric patients > 60 months

- Maturation appears better with microsurgical technique

8.1.2 Circumstances in which a CVC may be acceptable: patient size ?

Long-term patency R-C AVF in children < 10 kg: half-life 24 months

8.2 Stenosis surveillance

- An AVG stenosis surveillance protocol should be established to

detect venous anastomosis stenosis and direct patients for surgical

revision or PTA.

8.2 Stenosis surveillance: how?

Phase I: no monitoring

Phase II: dynamic venous pressure monitoring

Phase III: access blood flow monitoring

8.2 Stenosis surveillance: how?

2 needle access is mandatory for flow monitoring

8.2 Stenosis surveillance: how ?

8.2 Stenosis surveillance: how?

8.3 Catheter sizes, anatomic sites and configurations

- 8.3.1 Catheter size should be matched to patient size with the goal

of minimizing intraluminal trauma and obstruction of blood flow

while allowing sufficient blood flow for adequate HD.

- 8.3.2 External cuffed access should be placed in the internal jugular

with the distal tip placed in the right atrium.

- 8.3.3 The BFR of an external access should be minimally 3 to 5

ml/kg/min and should be adequate to deliver the prescribed HD

dose.

8.3.3 Catheter size

http://www.kidney.org/professionals/kdoqi/guideline_upHD_PD_VA/va_rec8.htm

8.3.3 Catheter size

Insertion of catheters > 6 Fr in children < 10 kg is associated with a significantly higher risk of complications

8.3.2 Anatomic site

8.3.2 Anatomic site

8.3.2 Anatomic site

Subclavian 74%Int. jugular 8%

Conclusions

- Preserve upper extremity peripheral and central veins for future

access

- Create permanent access in advance

- Establish a dedicated microsurgical approach

- Monitor access function, preferably by BFR monitoring

- When CVC is unavoidable, avoid a subclavian approach