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Ethier I, Hayat A, Pei J, Hawley CM, Johnson DW, Francis RS, Wong G, Craig JC, Viecelli AK, Htay H, Ng S, Leibowitz S, Cho Y. Peritoneal dialysis versus haemodialysis for people commencing dialysis. Cochrane Database Syst Rev 2024; 6:CD013800. [PMID: 38899545 PMCID: PMC11187793 DOI: 10.1002/14651858.cd013800.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs). OBJECTIVES To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023. SELECTION CRITERIA RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible. DATA COLLECTION AND ANALYSIS Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue. MAIN RESULTS A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty). AUTHORS' CONCLUSIONS The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.
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Affiliation(s)
- Isabelle Ethier
- Department of Nephrology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Health innovation and evaluation hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Ashik Hayat
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Juan Pei
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Ross S Francis
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Germaine Wong
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Samantha Ng
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Saskia Leibowitz
- Department of Nephrology, Logan Hospital, Meadowbrook, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
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Onwubiko C, Askenazi D, Ingram D, Griffin R, Russell RT, Mortellaro VE. Small tunneled central venous catheters as an alternative to a standard hemodialysis catheter in neonatal patients. J Pediatr Surg 2021; 56:2219-2223. [PMID: 33931256 DOI: 10.1016/j.jpedsurg.2021.03.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/24/2021] [Accepted: 03/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Continuous renal replacement therapy (CRRT) is difficult in neonates for several reasons, including problems with catheter placement and maintenance. We sought to compare outcomes between standard hemodialysis catheters (HDC) and 6Fr-tunneled central venous catheters (TC-6Fr). METHODS We evaluated neonates who received CRRT from December 2013 - January 2018. All patients received CRRT with the Aquadex (Baxter Corporation, Minneapolis, Minnesota) circuit. Data regarding patient demographics, CRRT indication, catheter days, reason for removal, and catheter-specific complications were analyzed. RESULTS Forty-six catheters were placed in 26 neonates; nine of these were 6Fr-tunneled catheters. The median age and mean weight at CRRT initiation was 9.5 days (IQR 4-31) and 3.5 kg (+/- 0.6 kg), respectively. TC-6Fr lasted longer (median of 28 days vs 10 days, p = 0.02), required fewer revisions (0 vs 0.16/10 catheter days) and were less commonly removed due to bleeding complications (0% vs 10.8%), occlusion (11.1% vs 18.9%), or malposition (0% vs 8.1%); none of these differences were statistically significant. TC-6Fr were associated with higher infection rates (33.3% vs 0%, p = 0.01) than HDC. CONCLUSIONS TC-6Fr use resulted in less need for catheter revisions and provided longer-lasting vascular access, which may influence infection rates. This catheter provides neonates in need of CRRT more reliable vascular access. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Chinwendu Onwubiko
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham AL 35233, United States
| | - David Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, United States; Pediatric Center for Acute Nephrology, Children's of Alabama, United States
| | - Daryl Ingram
- Pediatric Center for Acute Nephrology, Children's of Alabama, United States
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, United States
| | - Robert T Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham AL 35233, United States
| | - Vincent E Mortellaro
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham AL 35233, United States.
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Abstract
Acute kidney injury (AKI) is a highly prevalent disease entity in the NICU, affecting nearly one-quarter of critically ill neonates by some reports. Though medical management remains the mainstay in the treatment of AKI, renal replacement therapy (RRT) is indicated when conservative measures are unable to maintain electrolytes, fluid balance, toxins, or waste products within a safe margin. Several modalities of RRT exist for use in neonatal populations, including peritoneal dialysis, hemodialysis, and continuous RRT. It is the aim of this review to introduce each of these RRT modalities, as well as to discuss their technical considerations, benefits, indications, contraindications, and complications.
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Affiliation(s)
| | - Jason M Misurac
- Division of Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA
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Lemoine C, Keswani M, Superina R. Factors associated with early peritoneal dialysis catheter malfunction. J Pediatr Surg 2019; 54:1069-1075. [PMID: 30803792 DOI: 10.1016/j.jpedsurg.2019.01.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) catheter obstruction often leads to surgical revision and may require transition to hemodialysis. The purpose of this study was to evaluate risk factors (including omentectomy) associated with early PD catheter obstruction (<6 months from insertion). METHODS A retrospective review of all PD catheters inserted at a single high-volume referral center (2005-2018) was performed. 185 PD catheters were placed in 123 patients (45 female). Potential risk factors for early catheter obstruction were analyzed using Chi-square analysis (p < 0.05 considered statistically significant). RESULTS Median age at catheter insertion was 3.42 years (3 days-39 years). Early catheter obstruction occurred in 42 cases (22.7%). Median time to early obstruction was 24 days (3-118 days). Previous PD catheter placement (p = 0.9) or prior abdominal surgery (p = 0.89) was not associated with obstruction. Weight ≥ 10 kg (p = 0.011) and age ≥ 1 year (p = 0.048) were associated with a significantly higher incidence of obstruction. Overall, omentectomy was associated with a trend in reduction of early obstruction in patients with weight ≥ 10 kg (p = 0.08) and significantly in patients ≥1 year (p = 0.028). CONCLUSION Early PD catheter obstruction appears to occur more often in older patients with a higher weight. Concomitant omentectomy seems beneficial at reducing early catheter obstruction events in those patients. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Caroline Lemoine
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medecine, Chicago, IL, USA
| | - Mahima Keswani
- Division of Kidney Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medecine, Chicago, IL, USA
| | - Riccardo Superina
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medecine, Chicago, IL, USA.
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LaPlant MB, Saltzman DA, Segura BJ, Acton RD, Feltis BA, Hess DJ. Peritoneal dialysis catheter placement, outcomes and complications. Pediatr Surg Int 2018; 34:1239-1244. [PMID: 30203179 DOI: 10.1007/s00383-018-4342-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Peritoneal dialysis (PD) is a commonly used method for renal support in pediatric patients and can be associated with the risk of post-surgical complications. We evaluated method of placement of PD catheters with regard to post-surgical complications. METHODS PD catheters placed at two institutions between 2005 and 2017 were reviewed. Complication rates were evaluated based on method of placement, delayed usage, omentectomy, and patient age using Fisher's exact test, two-sided, with significance set at 0.05. Factors influencing complication were evaluated with multivariate logistic regression and Kaplan-Meier survival analysis. RESULTS There were 130 patients with 157 catheters placed, ranging in age from 1 day to 23 years. There was no significant difference in complication rate by method of placement or delayed usage. Infants were significantly more likely to experience leakage (21% vs 8%, p 0.036) and hernias (15% vs 5%, p 0.030). Patients that underwent an omentectomy were less likely to require a catheter replacement (7% vs 27%, p 0.004), and the catheters had a significantly higher survival rate (p 0.009). We found that laparoscopic intervention resulted in catheter salvage. Lateral exit sites may be a risk factor for catheter migration in some patients. CONCLUSIONS Omentectomy is associated with longer PD catheter survival. Laparoscopic salvage of dysfunctional catheters may be a valuable adjunct in management.
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Affiliation(s)
- Melanie B LaPlant
- Division of Pediatric Surgery, Department of Surgery, University of Minnesota, 2450 Riverside Ave S. MB 505, Minneapolis, MN, 55454, USA
| | - Daniel A Saltzman
- Division of Pediatric Surgery, Department of Surgery, University of Minnesota, 2450 Riverside Ave S. MB 505, Minneapolis, MN, 55454, USA
| | - Bradley J Segura
- Division of Pediatric Surgery, Department of Surgery, University of Minnesota, 2450 Riverside Ave S. MB 505, Minneapolis, MN, 55454, USA
| | - Robert D Acton
- Division of Pediatric Surgery, Department of Surgery, University of Minnesota, 2450 Riverside Ave S. MB 505, Minneapolis, MN, 55454, USA
| | - Brad A Feltis
- Pediatric Surgical Associates, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Donavon J Hess
- Division of Pediatric Surgery, Department of Surgery, University of Minnesota, 2450 Riverside Ave S. MB 505, Minneapolis, MN, 55454, USA.
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Radtke J, Schild R, Reismann M, Ridwelski RR, Kempf C, Nashan B, Rothe K, Koch M. Obstruction of peritoneal dialysis catheter is associated with catheter type and independent of omentectomy: A comparative data analysis from a transplant surgical and a pediatric surgical department. J Pediatr Surg 2018; 53:640-643. [PMID: 28728828 DOI: 10.1016/j.jpedsurg.2017.06.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) catheter occlusion is a common complication with up to 36% of catheter obstructions described in the literature. We present a comparison of complications and outcome after implantation of PD catheters in a transplant surgical and a pediatric surgical department. METHODS We retrospectively analyzed 154 PD catheters, which were implanted during 2009-2015 by transplant surgeons (TS, University Medical Center Hamburg-Eppendorf, Germany, n=85 catheters) and pediatric surgeons (PS, Charité University Medicine Berlin, Germany, n=69 catheters) in 122 children (median (range) age 3.0 (0.01-17.1) years) for acute (n=65) or chronic (n=89) renal failure. All catheters were one-cuffed or double-cuffed curled catheters, except that straight catheters were implanted into smaller children (n=19) by TS in Hamburg. RESULTS Patient characteristics and operation technique did not differ between the departments. Peritonitis was the most common complication (33 catheters, 21.4%). Leakage (n=18 catheters, 11.7%) occurred more often in children weighing <10kg (p<0.001). The incidence of obstruction and dysfunction was significantly higher in catheters used in PS than catheters used in TS (30.4% vs. 11.8%, p=0.004). Omentectomy did not reduce the incidence of catheter obstruction (p=1.0). Perforation at the catheter tips was larger and appeared to be rougher in catheters used in PS than the catheters in TS. CONCLUSIONS The type of catheter and presumably the type of perforation at the catheter tip may influence the incidence of peritoneal dialysis catheter obstruction.
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Affiliation(s)
- Josephine Radtke
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation Center UTC, Hamburg, Germany; Department of Pediatric Surgery, Charité University Medicine Berlin, Berlin, Germany.
| | - Raphael Schild
- Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Reismann
- Department of Pediatric Surgery, Charité University Medicine Berlin, Berlin, Germany
| | | | - Caroline Kempf
- Department of Pediatric Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Bjoern Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation Center UTC, Hamburg, Germany
| | - Karin Rothe
- Department of Pediatric Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Martina Koch
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation Center UTC, Hamburg, Germany
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Borzych-Duzalka D, Aki TF, Azocar M, White C, Harvey E, Mir S, Adragna M, Serdaroglu E, Sinha R, Samaille C, Vanegas JJ, Kari J, Barbosa L, Bagga A, Galanti M, Yavascan O, Leozappa G, Szczepanska M, Vondrak K, Tse KC, Schaefer F, Warady BA. Peritoneal Dialysis Access Revision in Children: Causes, Interventions, and Outcomes. Clin J Am Soc Nephrol 2017; 12:105-112. [PMID: 27899416 PMCID: PMC5220659 DOI: 10.2215/cjn.05270516] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 09/30/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Little published information is available about access failure in children undergoing chronic peritoneal dialysis. Our objectives were to evaluate frequency, risk factors, interventions, and outcome of peritoneal dialysis access revision. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were derived from 824 incident and 1629 prevalent patients from 105 pediatric nephrology centers enrolled in the International Pediatric Peritoneal Dialysis Network Registry between 2007 and 2015. RESULTS In total, 452 access revisions were recorded in 321 (13%) of 2453 patients over 3134 patient-years of follow-up, resulting in an overall access revision rate of 0.14 per treatment year. Among 824 incident patients, 186 (22.6%) underwent 188 access revisions over 1066 patient-years, yielding an access revision rate of 0.17 per treatment year; 83% of access revisions in incident patients were reported within the first year of peritoneal dialysis treatment. Catheter survival rates in incident patients were 84%, 80%, 77%, and 73% at 12, 24, 36, and 48 months, respectively. By multivariate logistic regression analysis, risk of access revision was associated with younger age (odds ratio, 0.93; 95% confidence interval, 0.92 to 0.95; P<0.001), diagnosis of congenital anomalies of the kidney and urinary tract (odds ratio, 1.28; 95% confidence interval, 1.03 to 1.59; P=0.02), coexisting ostomies (odds ratio, 1.42; 95% confidence interval, 1.07 to 1.87; P=0.01), presence of swan neck tunnel with curled intraperitoneal portion (odds ratio, 1.30; 95% confidence interval, 1.04 to 1.63; P=0.02), and high gross national income (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; P=0.01). Main reasons for access revisions included mechanical malfunction (60%), peritonitis (16%), exit site infection (12%), and leakage (6%). Need for access revision increased the risk of peritoneal dialysis technique failure or death (hazard ratio, 1.35; 95% confidence interval, 1.10 to 1.65; P=0.003). Access dysfunction due to mechanical causes doubled the risk of technique failure compared with infectious causes (hazard ratio, 1.95; 95% confidence interval, 1.20 to 2.30; P=0.03). CONCLUSIONS Peritoneal dialysis catheter revisions are common in pediatric patients on peritoneal dialysis and complicate provision of chronic peritoneal dialysis. Attention to potentially modifiable risk factors by pediatric nephrologists and pediatric surgeons should be encouraged.
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Affiliation(s)
- Dagmara Borzych-Duzalka
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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9
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Radtke J, Lemke A, Kemper MJ, Nashan B, Koch M. Surgical complications after peritoneal dialysis catheter implantation depend on children's weight. J Pediatr Surg 2016; 51:1317-20. [PMID: 26775194 DOI: 10.1016/j.jpedsurg.2015.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 11/30/2015] [Accepted: 12/05/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical complications are estimated to be as high as 30%-40% during the first 8 weeks after implantation of peritoneal dialysis (PD) catheters. METHODS 70 PD catheters which were implanted by transplant surgeons in 61 children (median age 3.3years, range 0.01-15.5years, 31 boys and 30 girls) in 2009-2014 were retrospectively reviewed. The incidence of complications and revisions during the first 6months after implantation was analyzed depending on children's weight and diagnosis. RESULTS 17 out of 70 catheters needed a surgical revision within 6months after implantation (24.3%). Peritonitis was the most common complication affecting 18.6% of peritoneal dialysis catheters followed by obstruction and dislocation, which it occurred in 9 (12.9%) and 7 (10%) catheters, respectively. Leakage (n=5) only occurred in children with a weight of less than 10kg. The total proportion of complications was higher in children with less than 10kg of weight (P<0.001). CONCLUSION PD is safe in children with acute renal failure and older children with chronic renal failure; however children with a weight of less than 10kg are more likely to develop complications.
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Affiliation(s)
- Josephine Radtke
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Anja Lemke
- Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Markus J Kemper
- Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Bjoern Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Martina Koch
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Carpenter JL, Fallon SC, Swartz SJ, Minifee PK, Cass DL, Nuchtern JG, Pimpalwar AP, Brandt ML. Outcomes after peritoneal dialysis catheter placement. J Pediatr Surg 2016; 51:730-3. [PMID: 26936290 DOI: 10.1016/j.jpedsurg.2016.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/07/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of this study was to review surgical outcomes after elective placement of peritoneal dialysis (PD) catheters in children with end-stage renal disease. METHODS Children with PD catheters placed between February 2002 and July 2014 were retrospectively reviewed. Outcomes were catheter life, late (>30days post-op) complications (catheter malfunction, catheter malposition, infection), and re-operation rates. Comparison groups included laparoscopic versus open placement, age<2, and weight<10kg. Univariate and multivariate analysis were performed. RESULTS One hundred sixteen patients had 173 catheters placed (122 open, 51 laparoscopic) with an average patient age of 9.7±6.3years. Mean catheter life was similar in the laparoscopic and open groups (581±539days versus 574±487days, p=0.938). The late complication rate was higher for open procedures (57% versus 37%, p=0.013). Children age<2 or weight<10kg had higher re-operation rates (64% versus 42%, p=0.014 and 73% versus 40%, p=0.001, respectively). Adjusted for age and weight, open technique remained a risk factor for late complications (OR 2.44, 95% CI 1.20-4.95) but not re-operation. DISCUSSION Laparoscopic placement appears to reduce the rate of late complications in children who require PD dialysis catheters. Children <2years age or <10kg remain at risk for complications regardless of technique.
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Affiliation(s)
- Jennifer L Carpenter
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sarah J Swartz
- Renal Service, Department of Pediatric Medicine, Texas Children's Hospital, Houston, TX
| | - Paul K Minifee
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Ashwin P Pimpalwar
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Sustaining life or prolonging dying? Appropriate choice of conservative care for children in end-stage renal disease: an ethical framework. Pediatr Nephrol 2015; 30:1761-9. [PMID: 25330877 DOI: 10.1007/s00467-014-2977-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/22/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
Due to technological advances, an increasing number of infants and children are surviving with multi-organ system dysfunction, and some are reaching end-stage renal disease (ESRD). Many have quite limited life expectancies and may not be eligible for kidney transplantation but families request dialysis as alternative. In developed countries where resources are available there is often uncertainty by the medical team as to what should be done. After encountering several of these scenarios, we developed an ethical decision-making framework for the appropriate choice of conservative care or renal replacement therapy in infants and children with ESRD. The framework is a practical tool to help determine if the burdens of dialysis would outweigh the benefits for a particular patient and family. It is based on the four topics approach of medical considerations, quality-of-life determinants, patient and family preferences and contextual features tailored to pediatric ESRD. In this article we discuss the basis of the criteria, provide a practical framework to guide these difficult conversations, and illustrate use of the framework with a case example. While further research is needed, through this approach we hope to reduce the moral distress of care providers and staff as well as potential conflict with the family in these complex decision-making situations.
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Lopez PJ, Troncoso B, Grandy J, Reed F, Ovalle A, Celis S, Reyes D, Letelier N, Zubieta R. Outcome of tunnelled central venous catheters used for haemodialysis in children weighing less than 15 kg. J Pediatr Surg 2014; 49:1300-3. [PMID: 25092094 DOI: 10.1016/j.jpedsurg.2014.02.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 01/28/2014] [Accepted: 02/10/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Central venous catheters (CVC) are frequently used for haemodialysis (HD) in children. However, there is paucity of information on the outcomes of CVCs when used for HD in very young patients. Our objective is to report the success, safety and complication rates of CVCs used for HD in children weighing less than 15 kg. MATERIALS AND METHODS This is a single-center retrospective study of all patients with end-stage renal disease (ESRD) weighing <15kg, who underwent a tunneled CVC placement for HD, between July 2006 and June 2012 at our institution. Analysed data included clinical background, age and weight at initiation of HD, outcome of HD, CVC vein insertion site, reason for removal, and catheter survival (in days). RESULTS Thirty-one CVC were placed in 11 patients weighing <15 kg, 8 males and 3 females. The main causes of ESRD were renal dysplasia and congenital nephrotic syndrome. At the beginning of HD, mean age was 27.5 (range 5-60) months and mean weight was 10.4 kg (4.5-13 kg). The preferred insertion site was the right internal jugular vein (90%). Mean duration of HD was 312 days. Mechanical factors were the main reason for catheter removal (39%). Mean catheter survival was 110 days/catheter. CONCLUSIONS We believe our study provides relevant information and encouraging data to support the use of CVC for HD in this cohort of infants; however, further improvement in prevention of catheter thrombosis and management of infections needs to be achieved.
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Affiliation(s)
- Pedro-Jose Lopez
- Pediatric Urology, Exequiel González Cortes Hospital, Santiago, Chile; Department of Pediatrics and Pediatric Surgery, School of Medicine, University of Chile, Santiago, Chile
| | | | - Jean Grandy
- Nephrology Services, Exequiel González Cortes Hospital, Santiago, Chile
| | - Francisco Reed
- Pediatric Urology, Exequiel González Cortes Hospital, Santiago, Chile
| | - Alejandra Ovalle
- Pediatric Urology, Exequiel González Cortes Hospital, Santiago, Chile
| | - Soledad Celis
- Pediatric Urology, Exequiel González Cortes Hospital, Santiago, Chile
| | - Danielle Reyes
- Pediatric Urology, Exequiel González Cortes Hospital, Santiago, Chile
| | - Nelly Letelier
- Pediatric Urology, Exequiel González Cortes Hospital, Santiago, Chile; Department of Pediatrics and Pediatric Surgery, School of Medicine, University of Chile, Santiago, Chile
| | - Ricardo Zubieta
- Pediatric Urology, Exequiel González Cortes Hospital, Santiago, Chile; Department of Pediatrics and Pediatric Surgery, School of Medicine, University of Chile, Santiago, Chile
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13
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Stone ML, LaPar DJ, Barcia JP, Norwood VF, Mulloy DP, McGahren ED, Rodgers BM, Kane BJ. Surgical outcomes analysis of pediatric peritoneal dialysis catheter function in a rural region. J Pediatr Surg 2013; 48:1520-7. [PMID: 23895966 PMCID: PMC4219559 DOI: 10.1016/j.jpedsurg.2013.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 02/05/2013] [Accepted: 02/05/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to analyze the experience with peritoneal dialysis (PD) at a high-volume, single center institution that supports a rural population. METHODS From 2000 to 2010, 88 children (median age: 1.98 years, [range: 2 days-20.2 years]) received 134 PD catheters for the management of acute and chronic renal failure. The primary outcome of interest was the incidence of primary PD catheter failure (replacement or revision within 60 days). Operative technique, longitudinal outcomes, and time intervals to transplantation were analyzed. RESULTS Median time to transplant from the institution of dialysis was 1.4 years [range: 0.3-6.4 years]. Primary catheter failure occurred in 24.6% of cases. Infants less than 6 months of age demonstrated an increased incidence of primary catheter failure (p = 0.02). The operative technique for catheter placement was not associated with the incidence of primary failure. Postoperative complications included peritonitis (22.7%), omental plugging (11.9%), pericatheter drainage (9.0%), and exit site infection (3.0%). CONCLUSION Peritoneal dialysis provides a safe and effective renal replacement therapy for regional pediatric centers that serve a rural population. However, primary catheter failure rates remain high at 24.6%. The surgical technique for placement had no effect on this failure rate in our patient population. Infants less than 6 months of age are at increased risk for primary catheter failure and warrant intensive surveillance.
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Affiliation(s)
- Matthew L. Stone
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Damien J. LaPar
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - John P. Barcia
- Department of Pediatrics, Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Victoria F. Norwood
- Department of Pediatrics, Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel P. Mulloy
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Eugene D. McGahren
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Bradley M. Rodgers
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Bartholomew J. Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA,Corresponding author. Division of Pediatric Surgery, University of Virginia Health System, Charlottesville, VA 22908-0709, USA. Tel.: +1 434 982 2796, fax: +1 434 243 0056. (B.J. Kane)
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14
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Risk factors for morbidity and mortality in pediatric patients with peritoneal dialysis catheters. J Pediatr Surg 2013; 48:197-202. [PMID: 23331815 DOI: 10.1016/j.jpedsurg.2012.10.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 10/13/2012] [Indexed: 11/20/2022]
Abstract
PURPOSE As peritoneal dialysis (PD) is the preferred long-term dialysis modality in the pediatric population, we sought to identify risk factors for mortality and reoperation. METHODS A retrospective review of patients undergoing PD catheter insertions at a single center from 1994-2009 was performed. The following variables were evaluated: age (<1 year), comorbidities, omentectomy, concomitant gastrostomy, and laparoscopic technique. Multivariable Cox regressions analyses were used to evaluate patient survival and reoperation-free survival of PD catheters. RESULTS 207 patients with a median age of 10 years underwent PD insertion. Mortality was 7% with a median follow up of 72 months. Reoperation for malfunction and infection was required in 49% of patients with a median PD catheter survival of 11 months. Reoperation for hernias occurred in 14% of patients. Multivariate Cox regressions analyses identified age <1 year, lack of omentectomy, concomitant gastrostomy, and prematurity as variables significantly associated with higher rates of mortality or reoperation. CONCLUSIONS In this large study of pediatric patients undergoing PD, higher complication rates were noted in infants less than one year of age. Concomitant gastrostomy was associated with a higher rate of reoperation for infection. Failure to perform omentectomy was associated with a higher rate of catheter failure.
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15
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Cribbs RK, Greenbaum LA, Heiss KF. Risk factors for early peritoneal dialysis catheter failure in children. J Pediatr Surg 2010; 45:585-9. [PMID: 20223324 DOI: 10.1016/j.jpedsurg.2009.06.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is uncertainty regarding the optimal approach for surgical placement of peritoneal dialysis (PD) catheters in children. Operative technique, catheter selection, and patient variables (eg, age or prior surgical history) may influence catheter lifespan. METHODS A retrospective review of all PD catheters placed at a tertiary children's medical center during a 6-year period was performed. Our primary outcome was catheter function 2 months after placement. Data were analyzed using Student 2-tailed t test or chi(2) analysis. RESULTS There were 121 PD catheters placed in 81 patients. The median primary functional catheter lifetime was 109 days. Primary PD catheter failure (within 2 months) occurred in 36 catheters (30%). Patients with primary catheter failure (8 +/- 7 years) were younger than patients with a functioning catheter at 2 months (12 +/- 5 years; P = .002). Catheters placed without simultaneous omentectomy were more likely to fail (P = .042). Catheter failure rate was not significantly different based upon operative technique or catheter type. CONCLUSION Omentectomy at the time of catheter placement decreased the risk of early catheter failure. In contrast, type of catheter or laparoscopic placement did not influence the likelihood of early catheter failure.
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Affiliation(s)
- Randolph K Cribbs
- Division of Pediatric Surgery, Department of Surgery, Emory University, Atlanta, GA 30322, USA
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Stringel G, McBride W, Weiss R. Laparoscopic placement of peritoneal dialysis catheters in children. J Pediatr Surg 2008; 43:857-60. [PMID: 18485953 DOI: 10.1016/j.jpedsurg.2007.12.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2007] [Accepted: 12/03/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) is preferred over hemodialysis. The aim of this study was to evaluate our experience with laparoscopic PD catheter placement and omentectomy in children. METHODS We reviewed all children (N = 21) who underwent laparoscopic placement of PD catheters and omentectomy. Ages ranged from 3 months to 16 years. Five children had previous major abdominal surgery and required extensive lysis of adhesions. During the same intervention, other surgical procedures were performed using laparoscopy or open technique, including umbilical hernia repair in 3, bilateral inguinal hernia repair in 3, ventral hernia repair in 2, gastrostomy in 4, kidney biopsy in 2, and cholecystectomy in 1. RESULTS Thirteen children received successful kidney transplantation and no longer needed dialysis. Two children still have functioning PD catheters. One patient developed membrane failure and was converted to hemodialysis. Four patients recovered enough renal function and no longer need dialysis. There were no complications related to the laparoscopic procedure. CONCLUSION Laparoscopy is ideal for PD catheter placement. It facilitates omentectomy, and it allows for the catheter to be placed in the proper position under direct vision and for lysis of adhesions to increase peritoneal surface. Other abdominal procedures can be performed laparoscopically at the same time.
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Affiliation(s)
- Gustavo Stringel
- Department of Surgery, Division of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA.
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Ramage IJ, Bailie A, Tyerman KS, McColl JH, Pollard SG, Fitzpatrick MM. Vascular access survival in children and young adults receiving long-term hemodialysis. Am J Kidney Dis 2005; 45:708-14. [PMID: 15806474 DOI: 10.1053/j.ajkd.2004.12.010] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The delivery of long-term hemodialysis therapy in children is complicated by smaller vascular caliber and the potential lifelong requirement for hemodialysis access. Various factors have resulted in the increased use of cuffed central venous catheters (CVLs) in preference to autologous arteriovenous fistulae (AVFs) and arteriovenous synthetic grafts (AVGs). The aim of this study is to compare CVL, AVF, and AVG survival and determine factors affecting their survival. METHODS A 20-year retrospective study was undertaken of pediatric patients receiving long-term hemodialysis therapy. Age, height, weight, body mass index, and sex were noted at each procedure, in addition to the presence of hypoalbuminemia, underlying diagnosis, type and site of vascular access, and effect of previous access surgery. The grade of operator also was noted. RESULTS Three hundred four vascular access procedures were performed on 114 patients, with a median age at initial access formation of 12.0 years (range, 4 weeks to 21.9 years). The most common procedure was CVL insertion (182 procedures) and then AVF formation (107 procedures), with only 15 AVGs created. Median censored survival was 3.14 years (95% confidence interval, 1.22 to 5.06) for AVFs and 0.6 years (95% confidence interval, 0.20 to 1.00) for CVLs. Factors adversely affecting vascular access survival were younger age, trainee operator, presence of hypoalbuminemia, and type of access undertaken, with AVF better than CVL. CONCLUSION This study shows increased survival of AVFs over CVLs and AVGs. Vascular access in children and adolescents may impact on future dialysis accessibility and should be undertaken by those most experienced in each technique.
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Affiliation(s)
- Ian J Ramage
- Renal Unit, Royal Hospital for Sick Children, Glasgow, Scotland.
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