Creating arteriovenous fistulas for children in Guatemala

Establishing an autogenous vascular access program in a Guatemalan comprehensive pediatric nephrology center

BACKGROUND

The Guatemalan Foundation for Children with Kidney Diseases collaborated with Bridge of Life, a not-for-profit charitable organization, to establish a vascular access program. We reviewed our experience with graded surgical responsibility and structured didactic training, creating arteriovenous fistulas (AVF) for Guatemalan children.

METHODS

Pediatric vascular access missions were completed from 2015 to 2023 and analyzed retrospectively. Follow-up was completed by the Guatemalan pediatric surgeons, nephrologists, and nursing staff. AVF patency and patient survival were evaluated by Kaplan-Meier life-table analysis with univariate and multivariable association between patient demographic variables by Cox proportional hazards models.

RESULTS

Among a total of 153 vascular access operations, there were 139 new patient procedures, forming the study group for this review. The mean age was 13.6 years, 42.6% were female, and the mean BMI was 17.3. Radial or ulnar artery-based direct AVFs were established in 100 patients (71.9%) and ten of the 25 transposition procedures. Brachial artery inflow was required in 29 direct AVFs (20.9%). Two patients underwent femoral vein transpositions. Access-related distal ischemia was not encountered. Seven of the AVF patients later required access banding for arm edema; all had previous dialysis catheters (mean = 9, range 4-12). Primary and cumulative patency rates were 84% and 86% at 12 months and 64% and 81% at 24 months, respectively. The median follow-up was 12 months. Overall patient survival was 84% and 67% at 12 and 24 months, respectively. There were no deaths related to AVF access.

CONCLUSIONS

Safe and functional AVFs were established in a teaching environment within a Guatemalan comprehensive pediatric nephrology center.

Creating hemodialysis autogenous access in children and adolescents

OBJECTIVE

End-stage renal disease (ESRD) in childhood and adolescence is rare, with relatively few published reports of pediatric ESRD vascular access. This study analyzes a 10-year experience creating arteriovenous fistulas (AVFs) in children and adolescents. Our goal is to review our strategy for creating functional autogenous vascular access in younger patients and report our results.

METHODS

We retrospectively reviewed data and outcomes for consecutive vascular access patients aged ≤19 years during a 10-year period. Each patient had preoperative vascular ultrasound mapping by the operating surgeon in addition to physical examination. A distal forearm radiocephalic AVF was the first access choice when feasible, and a proximal radial artery inflow AVF was the next option. Demographic data, inflow artery, venous outflow target, and required transposition vs direct AVFs were variables included in the analysis. Primary and cumulative patency were calculated by Kaplan-Meier analysis.

RESULTS

Thirty-seven AVFs were created in 35 patients. No grafts were used. Ages were 6 to 19 years (mean, 15 years), and 20 were male. Causes of ESRD included glomerular disease (n = 18) and urinary obstruction or reflux (n = 7), among others. Three had previous AVFs, and 10 were obese. The proximal radial artery supplied AVF inflow in 25 patients and the brachial artery in only seven. Eleven individuals required a transposition and one a vein translocation to the contralateral arm. No patients developed hand ischemia, although two later required banding procedures for high flow. Eleven patients had successful transplants. A single patient died, unrelated to the vascular access. Five AVFs failed. Of these, two had new successful AVFs created, two regained renal function, one was transplanted, and one declined other procedures. Primary and cumulative patency rates were 75% and 85% at 12 months, 70% and 85% at 24 months, and 51% and 85% at 36 months, respectively. Median follow-up was 16 months.

CONCLUSIONS

Creating an AVF for hemodialysis is a successful vascular access strategy for pediatric and adolescent patients. Proximal radial artery AVFs provided safe and functional access when a distal AVF was not feasible. Cumulative AVF patency was 85% at 36 months.

Clinical profile and outcome of arterio-venous fistulae in children on maintenance hemodialysis belonging to a low resource setting

INTRODUCTION

Arterio-venous fistula (AVF) is the recommended access of choice in children on maintenance hemodialysis. The challenges of creating and maintaining a fistula in children are many. The objective of our study was to study the clinical profile and outcomes of arteriovenous fistulae in children from a resource limited setting METHODS: A retrospective analysis of children who have had an AVF for maintenance hemodialysis from 2010 to 2020 was done. The centre protocol for creation and management of complications was followed. Failure of fistula to mature and failure to use fistula after it had been used were defined was primary failure and secondary failure respectively. Primary patency was defined as the time from maturation to first complication requiring intervention. The primary and secondary failure rates, risk factors for loss of primary patency and fistula survival were studied.

RESULTS

Thirty-six children (38 AVF) with median age of 11 (8,13) years were included. Brachio-cephalic anastomosis was the most common site (75%) of AVF. The primary and secondary failure rates were 5.5%(2/36) and 8.8%(3/34) respectively. The median time to loss of primary patency was 32 (16, 61.5) months. There were no particular risk factors identified for loss of primary patency. The 1- and 5-year survival was 91% and 73% respectively.

CONCLUSIONS

In resource limited settings, AVF is a feasible and durable access for maintenance hemodialysis in children with low failure rates.

CKD Care and Research in Guatemala: Overview and Meeting Report

On October 14–15, 2019, the 1st Symposium to Promote Chronic Kidney Disease (CKD) Research in Guatemala was held in Guatemala City, Guatemala. The Symposium hosted more than 50 attendees, including health care professionals, policy makers, researchers, and leaders of nongovernmental organizations. The meeting’s objectives were to (1) share clinical and health delivery experiences, (2) disseminate local research, and (3) establish consensus priorities for future research. In this report, we review the state of CKD nephrology in Guatemala, summarize experiences shared during the meeting from representatives of the clinical settings in Guatemala where CKD care is provided, and describe consensus priorities for future research.