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

Rukshana Shroff,Adam Kuchta,Andrew Arnold,Rosalie B Sterenborg,Francis Calder,Soundrie Padayachee,Nicholas Thomas,Lynsey Stronach

doi:10.1007/s00467-016-3428-z

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.

Highlights

Adequate vascular access is a key factor for successful haemodialysis (HD)
A multidisciplinary vascular clinic incorporating ultrasound assessment is key to maintaining young children on chronic haemodialysis via an Arteriovenous fistula (AVF)
In order to increase the use of AVFs in children on longterm HD, we developed a dedicated Vascular Access Clinic, run jointly by a transplant surgeon, paediatric nephrologist, dialysis nurse and clinical vascular scientist specialised in vascular sonography, to provide specialised care for the initiation and monitoring of AVFs in children

Summary

Introduction

Adequate vascular access is a key factor for successful haemodialysis (HD). The ideal vascular access, according to the National Kidney Foundation–Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines, should deliver an adequate flow rate in combination with durability and a low rate of complications [1]. An arteriovenous fistula (AVF) is generally considered to be the optimum access for HD in adults and, as suggested by an emerging body of evidence, in children [2,3,4]. AVFs have a significant primary failure rate (up to 40 % failure rate reported in the adult literature [7] and 25 % reported in a paediatric study [2]) and long maturation time and require expert surgical skills, they are associated with lower infection rates, fewer hospitalisations and improved access longevity [2, 6, 8, 9]. 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

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Results

Conclusion