Central venous catheter-related venous thrombosis in children with end-stage renal disease undergoing hemodialysis

Risk factors and incidence of central venous access device-related thrombosis in hospitalized children: a systematic review and meta-analysis

BACKGROUND

The risk factors for central venous access device-related thrombosis (CRT) in children are not fully understood. We used evidence-based medicine to find the risk factors for CRT by pooling current studies reporting risk factors of CRT, aiming to guide clinical diagnosis and treatment.

METHODS

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang databases was conducted. RevMan 5.4 was employed for data analysis.

RESULTS

The review included 47 studies evaluating 262,587 children with CVAD placement. Qualitative synthesis and quantitative meta-analysis identified D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection as the most critical risk factors for CRT. Primarily due to observational design, the quality of evidence was regarded as low certainty for these risk factors according to the GRADE approach.

CONCLUSION

Because fewer high-quality studies are available, larger sample sizes and well-designed prospective studies are still needed to clarify the risk factors affecting CRT. In the future, developing pediatric-specific CRT risk assessment tools is important. Appropriate stratified preventive strategies for CRT according to risk assessment level will help improve clinical efficiency, avoid the occurrence of CRT, and alleviate unnecessary suffering of children.

IMPACT

This is the latest systematic review of risk factors and incidence of CRT in children. A total of 47 studies involving 262,587 patients were included in our meta-analysis, according to which the pooled prevalence of CRT was 9.1%. This study identified several of the most critical risk factors affecting CRT in children, including D-dimer, insertion location, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection (CLABSI).

Construction and validation of a nomogram prediction model for the catheter-related thrombosis risk of central venous access devices in patients with cancer: a prospective machine learning study

Central venous access devices (CVADs) are integral to cancer treatment. However, catheter-related thrombosis (CRT) poses a considerable risk to patient safety. It interrupts treatment; delays therapy; prolongs hospitalisation; and increases the physical, psychological and financial burden of patients. Our study aims to construct and validate a predictive model for CRT risk in patients with cancer. It offers the possibility to identify independent risk factors for CRT and prevent CRT in patients with cancer. We prospectively followed patients with cancer and CVAD at Xiangya Hospital of Central South University from January 2021 to December 2022 until catheter removal. Patients with CRT who met the criteria were taken as the case group. Two patients with cancer but without CRT diagnosed in the same month that a patient with cancer and CRT was diagnosed were selected by using a random number table to form a control group. Data from patients with CVAD placement in Qinghai University Affiliated Hospital and Hainan Provincial People's Hospital (January 2023 to June 2023) were used for the external validation of the optimal model. The incidence rate of CRT in patients with cancer was 5.02% (539/10 736). Amongst different malignant tumour types, head and neck (9.66%), haematological (6.97%) and respiratory (6.58%) tumours had the highest risks. Amongst catheter types, haemodialysis (13.91%), central venous (8.39%) and peripherally inserted central (4.68%) catheters were associated with the highest risks. A total of 500 patients with CRT and 1000 without CRT participated in model construction and were randomly assigned to the training (n = 1050) or testing (n = 450) groups. We identified 11 independent risk factors, including age, catheterisation method, catheter valve, catheter material, infection, insertion history, D-dimer concentration, operation history, anaemia, diabetes and targeted drugs. The logistic regression model had the best discriminative ability amongst the three models. It had an area under the curve (AUC) of 0.868 (0.846-0.890) for the training group. The external validation AUC was 0.708 (0.618-0.797). The calibration curve of the nomogram model was consistent with the ideal curve. Moreover, the Hosmer-Lemeshow test showed a good fit (P > 0.05) and high net benefit value for the clinical decision curve. The nomogram model constructed in this study can predict the risk of CRT in patients with cancer. It can help in the early identification and screening of patients at high risk of cancer CRT.

Sonothrombolysis: State-of-the-Art and Potential Applications in Children

In recent years, advances in ultrasound therapeutics have been implemented into treatment algorithms for the adult population; however, the use of therapeutic ultrasound in the pediatric population still needs to be further elucidated. In order to better characterize the utilization and practicality of sonothrombolysis in the juvenile population, the authors conducted a literature review of current pediatric research in therapeutic ultrasound. The PubMed database was used to search for all clinical and preclinical studies detailing the use and applications of sonothrombolysis, with a focus on the pediatric population. As illustrated by various review articles, case studies, and original research, sonothrombolysis demonstrates efficacy and safety in clot dissolution in vitro and in animal studies, particularly when combined with microbubbles, with potential applications in conditions such as deep venous thrombosis, peripheral vascular disease, ischemic stroke, myocardial infarction, and pulmonary embolism. Although there is limited literature on the use of therapeutic ultrasound in children, mainly due to the lower prevalence of thrombotic events, sonothrombolysis shows potential as a noninvasive thrombolytic treatment. However, more pediatric sonothrombolysis research needs to be conducted to quantify the safety and ethical considerations specific to this vulnerable population.

Appropriateness of end-of-life care for children with genetic and congenital conditions: a cohort study using routinely collected linked data

This study aims to evaluate the appropriateness of end-of-life care for children with genetic and congenital conditions. This is a decedent cohort study. We used 6 linked, Belgian, routinely collected, population-level databases containing children (1-17) who died with genetic and congenital conditions in Belgium between 2010 and 2017. We measured 22 quality indicators, face-validated using a previously published RAND/UCLA methodology. Appropriateness of care was defined as the overall "expected health benefit" of given healthcare interventions within a healthcare system exceeding expected negative outcomes. In the 8-year study period, 200 children were identified to have died with genetic and congenital conditions. Concerning appropriateness of care, in the last month before death, 79% of children had contact with specialist physicians, 17% had contact with a family physician, and 5% received multidisciplinary care. Palliative care was used by 17% of the children. Concerning inappropriateness of care, 51% of the children received blood drawings in the last week before death, and 29% received diagnostics and monitoring (2 or more magnetic resonance imaging scans, computed tomography scans, or X-rays) in the last month.    Conclusion: Findings suggest end-of-life care could be improved in terms of palliative care, contact with a family physician and paramedics, and diagnostics and monitoring in the form of imaging. What is Known: • Previous studies suggest that end-of life care for children with genetic and congenital conditions may be subject to issues with bereavement, psychological concerns for child and family, financial cost at the end of life, decision-making when using technological interventions, availability and coordination of services, and palliative care provision. Bereaved parents of children with genetic and congenital conditions have previously evaluated end-of-life care as poor or fair, and some have reported that their children suffered a lot to a great deal at the end of life. • However, no peer-reviewed population-level quality evaluation of end-of-life care for this population is currently present. What is New: • This study provides an evaluation of the appropriateness of end-of-life care for children who died in Belgium with genetic and congenital conditions between 2010 and 2017, using administrative healthcare data and validated quality indicators. The concept of appropriateness is denoted as relative and indicative within the study, not as a definitive judgement. • Our study suggests improvements in end-of-life care may be possible, for instance, in terms of the provision of palliative care, contact with care providers next to the specialist physician, and diagnostics and monitoring in terms of imaging (e.g., magnetic resonance imaging, computed tomography scans). Further empirical research is necessary, for instance, into unforeseen and foreseen end-of-life trajectories, to make definitive conclusions about appropriateness of care.

Characteristic CT angiography findings and clinical value of catheter-related central venous thrombosis in hemodialysis patients with end-stage renal disease

BACKGROUND

Central catheter-related thrombosis (CRT) is the most common catheter-related complication in patients with end-stage renal disease (ESRD) but is often underappreciated and misdiagnosed by radiologist.

PURPOSE

To find the computed tomography angiography (CTA) characteristics of central CRT, then raise the diagnosis of this disorder.

MATERIAL AND METHODS

A total of 301 eligible patients with ESRD who experienced both chest multi-phase multidetector CTA (MDCTA) and digital subtraction angiography were enrolled in the final analysis. The location, shape, and related signs of the central CRT in MDCTA images were evaluated. Independent-samples T test, chi-square test, and binary logistic regression were analyzed using SPSS software.

RESULTS

In total, 166 patients were found to have CRT using MDCTA, and this was verified by DSA. Central CRT was usually irregular in the superior vena cava segment, and the angle of the contact area between central CRT and catheter was <180° (all P < 0.05). Age, collateral circulation, and venous stenosis were shown to have significant differences when compared to patients without CRT (all P < 0.05), but there were no significant differences about the sex or catheter insertion site. In addition, age and collateral circulation were the factors found to be significantly associated with thrombosis (P < 0.05). In particular, the thrombosis was 2.213 times more likely to be found in those patients with collateral circulation (odds ratio = 2.213, 95% confidence interval = 1.236-3.961).

CONCLUSION

Chest multi-phase MDCTA can effectively reduce the missed diagnosis and misdiagnosis of central CRT. It is worth paying more attention to the central CRT especially when the collateral circulation is observed.

A reappraisal of pediatric thoracic surface anatomy

Accurate knowledge of surface anatomy is essential for physical examination, invasive procedures, and anatomy education. Individual factors such as age make surface landmarks variable so accurate descriptions are needed. The aim of this study is to describe age-related surface landmarks for intrathoracic structures in children. A total of 156 thoracic computed tomography scans of children aged 0-18 years were categorized into six groups, and the associations between major intrathoracic structures and surface landmarks were analyzed. Sternal angle is an accurate surface landmark for the azygos vein-superior vena cava junction in all age groups. However, the aortic arch (except in the 0-1 year group), the bifurcation of the pulmonary trunk and the tracheal bifurcation in those aged 15-18 years were not within this plane. The left brachiocephalic vein was located behind the ipsilateral sternoclavicular joint except in the 1-3 years group, and the right was behind it in children older than 6 years. The apex of heart was at the 5th intercostal space level in the 0-1 and 12-18 years groups; however, it was higher in the other groups. The lower borders of the lungs were at the sixth costal cartilage level in the midclavicular line, eighth intercostal space level in the midaxillary line, and T12 adjacent to the vertebral column in the 15-18 years group; the lower borders were at higher levels in younger children. Defining the variations in surface anatomy by in vivo studies will increase its clinical and pedagogical value.

Hemostatic changes in patients undergoing hemodialysis: differences between central venous catheters and arterio-venous fistulas

BACKGROUND

Failure to mature the fistula in patients undergoing hemodialysis leads to prolonged use of the central venous catheter (CVC) and can compromise the patency of the catheter and the arteriovenous fistula (AVF) due to thrombus development.

OBJECTIVE

to evaluate hemostatic changes in patients undergoing hemodialysis with prolonged use of CVC or AVF.

METHOD

cross-sectional study with a total of 200 adult participants who were divided into the following groups: I:control; II: patients who had 5 to 8 months of CVC insertion; III: patients who had 9 to 36 months of insertion; IV patients who had 5 to 8 months of AVF and V: patients who had 9 to 36 months of AVF. Platelet activation was investigated by expressions of GPIIb/IIIa and p-selectin using flow cytometry. The Elisa-thrombomodulin test was used to compare groups III and V.

RESULTS

the p-selectin percentage expression of group I was 15.30 (12.30-16.80), II 23.25 (20.75-30.55) and III 54.00 (44.75 -59.29) were significant (p<0.001). Groups I, IV and V were also significant (p<0.001). The median fluorescence for GPIIb/IIIa for groups I, II and III were significant (p<0.0001). As for the Elisa test, an increased absorbance of thrombomodulin was verified in patients who used the CVC 4372 (3951-4733) when compared to those patients who used the AVF 2162 (1932-2485) (p<0.0001).

CONCLUSION

It can be concluded that CVC patients had a larger platelet expression of GPIIb/IIIa and p-selectin than AVF patients. The high concentration of thrombomodulin in CVC patients may suggest a greater stimulation of the intrinsic than extrinsic coagulation pathways.

Computational investigation of the haemodynamics shows criticalities of central venous lines used for chronic haemodialysis in children

BACKGROUND

Haemodialysis is a life-saving treatment for children with kidney failure. The majority of children have haemodialysis through central venous lines (CVLs). The use of CVLs in pediatric patients is often associated to complications which can lead to their replacement. The aim of this study is to investigate haemodynamics of pediatric CVLs to highlight the criticalities of different line designs.

METHODS

Four models of CVLs for pediatric use were included in this study. The selected devices varied in terms of design and sizes (from 6.5 Fr to 14 Fr). Accurate 3D models of CVLs were reconstructed from high-resolution images including venous and arterial lumens, tips and side holes. Computational fluid dynamics (CFD) analyses were carried out to simulate pediatric working conditions of CVLs in ideal and anatomically relevant conditions.

RESULTS

The arterial lumens of all tested CVLs showed the most critical conditions with the majority of blood flowing through the side-holes. A zone of low flow was identified at the lines' tip. The highest shear stresses distribution (>10 Pa) was found in the 8 Fr line while the highest platelet lysis index in the 10 Fr model. The analysis on the anatomical geometry showed an increase in wall shear stress measured in the 10 F model compared to the idealised configuration. Similarly, in anatomical models an increased disturbance and velocity of the flow was found inside the vein after line placement.

CONCLUSION

This study provided a numerical characterization of fluid dynamics in pediatric CVLs highlighting performance criticalities (i.e. high shear stresses and areas of stagnation) associated to specific sizes (8 Fr and 10 Fr) and conditions (i.e. anatomical test).

Pediatric hemodialysis access

Pediatric hemodialysis access is a demanding field. Procedures are infrequent, technically challenging, and associated with high complication and failure rates. Each procedure affects subsequent access and transplants sites. The choice is made easier and outcomes improved when access decisions are made by a multidisciplinary, pediatric, hemodialysis access team. This manuscript reviews the current literature and offers technical suggestions to improve outcomes.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Terapia de reemplazo renal, una alternativa para la calidad de vida de los pacientes

La enfermedad renal crónica es una patología causada por la pérdida del funcionamiento del riñón con una filtración glomerular alterada por más de tres meses, por lo que es necesario recibir terapia de reemplazo renal consistente en la sustitución de esta función mediante la extracción de líquidos de la sangre y su filtración a través de membranas semipermeables, en especial para mantener la homeostasis mediante la eliminación de sustancias tóxicas nitrogenadas y desechos acumulados. Estos procedimientos y en particular la hemodiálisis pueden presentar diversas complicaciones debido a que son procesos invasivos. Cabe mencionar que los pacientes en terapia de reemplazo presentan una disminución de la calidad de vida sobre todo a nivel físico y psicológico, a costa de mantener una mejor condición de su salud renal.

Thromboembolic Complications of Vascular Catheters Used for Pediatric Continuous Renal Replacement Therapy: Prevalence in a Single-Center, Retrospective Cohort

OBJECTIVES

Pediatric venous thromboembolic events are commonly associated with in situ central venous catheters. The risk for severe venous thromboembolism increases if a larger portion of the vessel lumen is occupied by the central venous catheter. A functioning vascular catheter is required when the continuous renal replacement therapy is used in critically ill children. Due to the high blood flow required for continuous renal replacement therapy, the external diameter of the catheter needs to be larger than a conventional central venous catheter used for venous access, potentially increasing the risk of venous thromboembolism. However, children on continuous renal replacement therapy often receive systemic anticoagulation to prevent filter clotting, possibly also preventing venous thromboembolism. The frequency of catheter-related venous thromboembolic events in this setting has not been described. Our main objective was to determine the prevalence of catheter-related venous thromboembolism in pediatric continuous renal replacement therapy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary multidisciplinary academic pediatric hospital.

PATIENTS

Patients 0-18 years old with a vascular catheter used for continuous renal replacement therapy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In our series of 80 patients, we used 105 vascular catheters. The median age of the patients was 10 months and PICU mortality rate was 21%. Venous thromboembolic events were considered to be catheter related if located in the same vein as the vascular catheter and radiologically verified. Six (5.7%) catheter-related venous thromboembolic events were found. The clinically relevant complications of venous thromboembolism included superior vena cava syndrome and catheter dysfunction. In one patient, severe and life-threatening pulmonary embolism occurred. In comparison with patients without venous thromboembolism, venous thromboembolic events were associated with lower body weight (p = 0.03) and longer durations of continuous renal replacement therapy (p < 0.01), mechanical ventilation (p = 0.03), and PICU stay (p < 0.01). Five out of six venous thromboembolisms appeared in neonates.

CONCLUSIONS

Catheter-related venous thromboembolism is a clinically relevant complication of pediatric continuous renal replacement therapy, with a prevalence of 5.7% in our cohort. Clinicians involved in pediatric continuous renal replacement therapy need to be vigilant for symptoms of venous thromboembolisms and initiate appropriate treatment as soon as possible.

The incidence and risk factors for venous thromboembolism in adolescent and young adult oncology patients

BACKGROUND

Venous thromboembolism (VTE) is a known complication among pediatric and adult cancer patients. Adolescent and young adult oncology (AYAO) patients have unique biological and physiological characteristics that make them distinct from other populations. Our objective was to study the VTE incidence, risk factors, and outcomes, which have been understudied in this population.

PROCEDURE

A retrospective case-control study was conducted on AYAO participants with new or relapsed cancer and an imaging confirmed VTE from January 2011 to November 2016 at our institution. Eligible AYAO participants without a history of VTE were designated as controls and were randomly selected from our institution's tumor registry. Demographics, medical history, surgeries, central venous catheter (CVC) data, VTE diagnosis and treatment, relapses, and deaths were abstracted.

RESULTS

Thirty-five VTE cases and 70 controls were included in this analysis. Eighty percent of cases had leukemia or lymphoma (vs. a solid tumor) compared to 58% of controls. The majority of VTEs (57%) were CVC associated, and more than 70% of cases had more than one CVC placed during their cancer treatment versus 34% of controls. Infection was associated with increased VTE risk (OR = 6.35, 95% CI = 2.30, 17.55, p < .0001). VTE cases had increased cancer relapse (23% vs. 10%) and mortality rates (29% vs. 16%) than controls.

CONCLUSION

AYAO participants with a VTE were more likely to have leukemia or lymphoma, more than one CVC or infection. Further studies are needed to identify patients who would benefit from modifiable prevention measures, such as limiting to one CVC, preventing infections, or considering prophylactic anticoagulation for those with a liquid tumor.

Challenges of long-term vascular access in pediatric hemodialysis: Recommendations for practitioners

Kidney transplantation is the preferred treatment of end-stage renal disease in children. However, time to transplant varies, making a well-functioning long-term vascular access essential for performing hemodialysis efficiently and without disruption until a kidney becomes available. However, establishing long-term vascular access in pediatric patients can present distinct challenges due to this population's unique characteristics, such as smaller body size and lower-diameter blood vessels. There are three main pediatric long-term vascular access options, which include central venous catheters (CVC), arteriovenous fistula (AVF), and arteriovenous graft (AVG). CVC are currently the most widely used modality, although various studies and guidelines recommend AVF or AVG as the preferred option. Although AVF should be used whenever possible, it is crucial that clinicians consider factors such as patient size, physical exam findings, comorbidities, predicted duration of treatment to decide on the most optimal long-term vascular access modality. This article reviews the three long-term vascular access methods in children and the benefits and complications of each.