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de Winter EP, Wilschut D, Plasmans K, Eefting D, van der Steenhoven T, Putter H, Rotmans J, van der Bogt K. Intraoperative transit time flow measurement predicts maturation of radiocephalic arteriovenous fistulas. J Vasc Surg 2024; 80:232-239. [PMID: 38432488 DOI: 10.1016/j.jvs.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/18/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The arteriovenous fistula (AVF) is the first choice for gaining vascular access for hemodialysis. However, 20% to 50% of AVFs fail within 4 months after creation. Although demographic risk factors have been described, there is little evidence on the intraoperative predictors of AVF maturation failure. The aim of this study was to assess the predictive value of intraoperative transit time flow measurements (TTFMs) on AVF maturation failure. METHODS In this retrospective cohort study, intraoperative blood flow, measured using TTFM, was compared with AVF maturation after 6 weeks in 55 patients. Owing to its significantly higher prevalence and risk of nonmaturation, the radiocephalic AVF (RCAVF) was the main focus of this study. A recommended cutoff point for high vs low intraoperative blood flow was determined for RCAVFs, using a receiver operating characteristic curve. RESULTS The average intraoperative blood flow in RCAVFs was 156 mL/min. Patients with an intraoperative blood flow equal or lower than the determined cutoff point of 160 mL/min, showed a 3.03 times increased risk of AVF maturation failure after 6 weeks, compared with patients with a higher intraoperative blood flow (P < .001). CONCLUSIONS The intraoperative blood flow in RCAVFs measured by TTFM provides an adequate means of predicting AVF nonmaturation 6 weeks after surgery. For RCAVFs, a cutoff point for intraoperative blood flow of 160 mL/min is recommended for maximum sensitivity and specificity to predict AVF maturation failure after 6 weeks.
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Affiliation(s)
- Eduard Pierre de Winter
- Haaglanden Medical Centre, the Hague, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Kim Plasmans
- Haaglanden Medical Centre, the Hague, the Netherlands
| | - Daniel Eefting
- Haaglanden Medical Centre, the Hague, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands; University Vascular Center West, Leiden, The Hague, and Delft, the Netherlands
| | - Tim van der Steenhoven
- Haaglanden Medical Centre, the Hague, the Netherlands; University Vascular Center West, Leiden, The Hague, and Delft, the Netherlands
| | - Hein Putter
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Joris Rotmans
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Koen van der Bogt
- Haaglanden Medical Centre, the Hague, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands; University Vascular Center West, Leiden, The Hague, and Delft, the Netherlands.
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Reijman MD, Kusters DM, Groothoff JW, Arbeiter K, Dann EJ, de Boer LM, de Ferranti SD, Gallo A, Greber-Platzer S, Hartz J, Hudgins LC, Ibarretxe D, Kayikcioglu M, Klingel R, Kolovou GD, Oh J, Planken RN, Stefanutti C, Taylan C, Wiegman A, Schmitt CP. Clinical practice recommendations on lipoprotein apheresis for children with homozygous familial hypercholesterolaemia: An expert consensus statement from ERKNet and ESPN. Atherosclerosis 2024; 392:117525. [PMID: 38598969 DOI: 10.1016/j.atherosclerosis.2024.117525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/08/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Abstract
Homozygous familial hypercholesterolaemia is a life-threatening genetic condition, which causes extremely elevated LDL-C levels and atherosclerotic cardiovascular disease very early in life. It is vital to start effective lipid-lowering treatment from diagnosis onwards. Even with dietary and current multimodal pharmaceutical lipid-lowering therapies, LDL-C treatment goals cannot be achieved in many children. Lipoprotein apheresis is an extracorporeal lipid-lowering treatment, which is used for decades, lowering serum LDL-C levels by more than 70% directly after the treatment. Data on the use of lipoprotein apheresis in children with homozygous familial hypercholesterolaemia mainly consists of case-reports and case-series, precluding strong evidence-based guidelines. We present a consensus statement on lipoprotein apheresis in children based on the current available evidence and opinions from experts in lipoprotein apheresis from over the world. It comprises practical statements regarding the indication, methods, treatment goals and follow-up of lipoprotein apheresis in children with homozygous familial hypercholesterolaemia and on the role of lipoprotein(a) and liver transplantation.
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Affiliation(s)
- M Doortje Reijman
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - D Meeike Kusters
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jaap W Groothoff
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Klaus Arbeiter
- Division of Paediatric Nephrology and Gastroenterology, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Eldad J Dann
- Blood Bank and Apheresis Unit Rambam Health Care Campus, Haifa, Israel
| | - Lotte M de Boer
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Antonio Gallo
- Sorbonne Université, INSERM, UMR 1166, Lipidology and Cardiovascular Prevention Unit, Department of Nutrition, APHP, Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Susanne Greber-Platzer
- Clinical Division of Paediatric Pulmonology, Allergology and Endocrinology, Department of Paediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Jacob Hartz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Lisa C Hudgins
- The Rogosin Institute, Weill Cornell Medical College, New York, NY, USA
| | - Daiana Ibarretxe
- Vascular Medicine and Metabolism Unit (UVASMET), Hospital Universitari Sant Joan, Spain; Universitat Rovira i Virgili, Spain; Institut Investigació Sanitària Pere Virgili (IISPV)-CERCA, Spain; Centro de Investigación Biomédica en Red en Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Spain
| | - Meral Kayikcioglu
- Department of Cardiology, Medical Faculty, Ege University, 35100, Izmir, Turkey
| | - Reinhard Klingel
- Apheresis Research Institute, Stadtwaldguertel 77, 50935, Cologne, Germany(†)
| | - Genovefa D Kolovou
- Metropolitan Hospital, Department of Preventive Cardiology, 9, Ethn. Makariou & 1, El. Venizelou, N. Faliro, 185 47, Athens, Greece
| | - Jun Oh
- University Medical Center Hamburg/Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Atherosclerosis & Ischemic Syndromes, Amsterdam, the Netherlands
| | - Claudia Stefanutti
- Department of Molecular Medicine, Lipid Clinic and Atherosclerosis Prevention Centre, 'Umberto I' Hospital 'Sapienza' University of Rome, I-00161, Rome, Italy
| | - Christina Taylan
- Paediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Albert Wiegman
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
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Blair N, Patil P, Nguyen D, Paudyal-Nepal B, Iorember F. Antibiotic lock solutions as adjunct therapy for catheter-related blood stream infections in pediatric hemodialysis patients. Front Pediatr 2024; 12:1379895. [PMID: 38665376 PMCID: PMC11043483 DOI: 10.3389/fped.2024.1379895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
The predominant use of intravenous catheters as primary access type in the pediatric hemodialysis population is associated with an increased risk of catheter related blood stream infections. While strict adherence to catheter placement and long-term care guidelines have helped to decrease the incidence of these infections, blood stream infections remain an infection burden in pediatric patients with long term hemodialysis catheters. The formation of biofilms on the surfaces of these catheters has been shown to be a source of microbes causing blood stream infections. One of the strategies for preventing bacterial colonization, inhibiting microbial multiplication, and suppressing the seeding of these microbes from biofilms upon maturation, has been the use of antibiotic-based lock solutions in-between dialysis treatments. Although clinical guidelines for the use of antibiotic lock solutions are yet to be developed, available evidence suggests a beneficial role of antibiotic lock solutions in the management of catheter related blood stream infections. Additionally, a clear understanding of how biofilms are formed and their role in the pathogenesis of catheter related bloodstream infection will facilitate the development of solutions that can prevent biofilm formation and inhibit their multiplication, maturation and seeding into the bloodstream.
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Affiliation(s)
- N. Blair
- School of Medicine, Texas A&M University School of Medicine, College Station, TX, United States
| | - P. Patil
- Department of Pharmacy, Driscoll Children’s Hospital, Corpus Christi, TX, United States
| | - D. Nguyen
- Department of Pharmacy, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - B. Paudyal-Nepal
- Department of Nephrology, Texas Children’s Hospital, Austin, TX, United States
| | - F. Iorember
- Department of Nephrology, Driscoll Children's Hospital, Corpus Christi, TX, United States
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Bakkaloğlu SA, Ezgü D, Hari P, Boyer O, Schaefer F. Perception and knowledge of pediatric nephrologists on evidence-based guideline development methodology. Pediatr Nephrol 2024; 39:1015-1018. [PMID: 37648842 DOI: 10.1007/s00467-023-06139-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Sevcan A Bakkaloğlu
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - Defne Ezgü
- Faculty of Medicine, Başkent University, Ankara, Turkey
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Olivia Boyer
- Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, APHP, Institut Imagine, Université Paris Cité, Inserm U1163, Paris, France
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Stroescu R, Comsa S, Chisavu F, Gafencu M. Case Report: Vascular access in paediatric haemodialysis patients-creating and maintaining the patency of an arteriovenous fistula. Front Surg 2024; 11:1181802. [PMID: 38567360 PMCID: PMC10985175 DOI: 10.3389/fsurg.2024.1181802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Paediatric vascular access is a demanding field. The need for a multidisciplinary team is mandatory in children with end-stage kidney disease (ESKD). Central venous catheters (CVCs) remain the preferred option worldwide. Recent emerging data demonstrated the benefits of using arteriovenous fistulas (AVFs) in the paediatric population for long-term vascular access. The small vessel size in children represents a surgical challenge for vascular access. Case presentation We report three cases from our haemodialysis department and the difficulty in maintaining permanent vascular access. The first case is an adolescent girl who required a change in vascular approach after multiple central venous catheter (CVC) infections and catheter thrombosis secondary to thrombophilia. Three AVFs were performed but failure occurred early. The patient was also diagnosed with a complex vascular thrombosis with total occlusion of the inferior vena cava and completed distal thrombosis of the superior vena cava. A permanent CVC was placed in the right jugular vein with the tip in the azygos vein. The second case is of an adolescent boy with systemic vasculitis with multiple CVC infections secondary to immunosuppression. The first thrombosis of two right AVFs occurred early with the development of a pseudo-aneurysm that required surgical intervention. The left brachial-cephalic fistula required surgery for closing the collaterals, repositioning and superficialisation. The third case is an adolescent boy with one surgical stage brachial-basilic left AVF and difficulties in venous puncturing. Conclusion Vascular access in paediatric haemodialysis remains a demanding field. There is a need for a multidisciplinary team, consisting of a vascular surgeon and an interventional radiologist specialising in children.
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Affiliation(s)
- Ramona Stroescu
- “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania
- 4th Pediatric Clinic, “Louis Țurcanu” Children's Clinical Sand Emergency Hospital, Timișoara, Romania
| | - Serban Comsa
- “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania
- Department of Microscopic Morphology/Histology, Angiogenesis Research Center, “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania
| | - Flavia Chisavu
- “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania
- 4th Pediatric Clinic, “Louis Țurcanu” Children's Clinical Sand Emergency Hospital, Timișoara, Romania
- Faculty of Medicine “Victor Babes”, Centre for Molecular Research in Nephrology and Vascular Disease, Timișoara, Romania
| | - Mihai Gafencu
- “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania
- 4th Pediatric Clinic, “Louis Țurcanu” Children's Clinical Sand Emergency Hospital, Timișoara, Romania
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6
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Phi L, Jayroe H, Mushtaq N, Kempe K, Nelson PR, Zamor K, Iyer P, Motta F, Jennings WC. Creating hemodialysis autogenous access in children and adolescents. J Vasc Surg 2024; 79:651-661. [PMID: 37952781 DOI: 10.1016/j.jvs.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/31/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
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.
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Affiliation(s)
- Lucas Phi
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Hannah Jayroe
- Department of Surgery, Jack C. Montgomery Department of Veterans Affairs Medical Center, Muskogee, OK
| | - Nasir Mushtaq
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Tulsa, OK
| | - Kelly Kempe
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Peter R Nelson
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Kimberly Zamor
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Prashanth Iyer
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Fernando Motta
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - William C Jennings
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK.
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Cruz-Centeno N, Stewart S, Marlor DR, Rivard DC, Daniel JM, Oyetunji TA, Hendrickson RJ. Exchange of Extracorporeal Membrane Oxygenation Cannulas for Hemodialysis Catheters in Children Requiring Renal Replacement Therapy. Am Surg 2024; 90:216-219. [PMID: 37609992 DOI: 10.1177/00031348231198119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
BACKGROUND Pediatric patients requiring extracorporeal membrane oxygenation (ECMO) may require renal replacement therapy even after decannulation. However, data regarding transition from ECMO cannulation to a hemodialysis catheter in pediatric patients is not currently available. METHODS Patients <18 years old who had an ECMO cannula exchanged for a hemodialysis catheter during decannulation at a tertiary care children's center from January 2011 to September 2022 were identified. Data was collected from the electronic medical record. RESULTS A total of 10 patients were included. The cohort was predominantly male (80.0%, n = 8) with a median age of 1 day (IQR 1.0, 24.0). All ECMO cannulations were veno-arterial in the right common carotid artery and internal jugular vein. The median time on ECMO was 8.5 days (IQR 6.0, 15.0). One patient had the venous cannula exchanged for a tunneled hemodialysis catheter during decannulation, two were transitioned to peritoneal dialysis, and seven had the temporary hemodialysis catheter converted to a tunneled catheter by Interventional Radiology (when permanent access was required) at a median time of 10 days (IQR 8.0, 12.5). Of these 7 patients, 28.6% (n = 2) developed catheter-associated infection within 30 days of replacement, with one requiring catheter replacement. Transient bloodstream infection occurred in 10.0% (n = 1) within 30 days of ECMO cannula exchange. CONCLUSION Venous ECMO cannula exchange for a hemodialysis catheter in children requiring renal replacement therapy after decannulation is possible as a bridge to a permanent hemodialysis or peritoneal catheter if renal function does not recover, while supporting vein preservation.
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Affiliation(s)
- Nelimar Cruz-Centeno
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shai Stewart
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Derek R Marlor
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Douglas C Rivard
- Department of Radiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - John M Daniel
- Department of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Tolulope A Oyetunji
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Richard J Hendrickson
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- Department of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
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Salah DM, Fadel FI, Abdel Mawla MA, Mooty HNA, Ghobashy ME, Salem AM, Fathallah MG, Abd Alazem EA. Vascular access challenges in hemodialysis children. Ital J Pediatr 2024; 50:11. [PMID: 38254126 PMCID: PMC10804700 DOI: 10.1186/s13052-024-01590-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 01/07/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Hemodialysis (HD) success is dependent mainly on vascular access (VA). The aim of this study is to share the experience of Pediatric Nephrology Unit (PNU), Cairo University Children's Hospital (CUCH), with VA-related obstacles in end stage kidney disease (ESKD) HD children. METHODS This is a retrospective analysis of VA related data of 187 ESKD children received regular HD over 3 year duration (2019-2021). Kaplan-Meier curves were used to present arteriovenous fistula (AVF) and cuffed catheters survivals. RESULTS Uncuffed central venous catheter (CVC) was the primary VA for HD in up to 97.3% with 2.7% of patients had AVF performed and attained maturation before initiation of regular HD. Fifty-six (29.9%) patients have inserted 120 tunneled CVCs. AVFs & AV grafts (AVF) were performed in 79 (42.2%) and 6 (3.2%) patients respectively. There were 112 uncuffed CVCs implanted beneath the screen in Rt internal jugular vein (IJV) (44%) Lt IJV (17%), right internal mammary vein (2.7%) while Trans hepatic (TH) technique was used to place 39 uncuffed CVCs (34%) in the inferior vena cava (IVC). Catheter-related bacteremia (CRB) was the most frequent complication in uncuffed and cuffed CVCs (2.58 / 100 catheters day and 10.1 /1000 catheter days respectively). AVFs achieved a high success rate (83%) after 757.71 ± 512.3 functioning days. CONCLUSION Native AVF is the preferred VA for pediatric HD but its creation is limited by the small sized vessels where non-cuffed CVC could be a reasonable relatively long-term alternative. Challenging situations (occluded central veins) could benefit from TH technique of CVC insertion in IVC.
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Affiliation(s)
- Doaa M Salah
- Department of Pediatrics, Pediatric Nephrology and Transplantation Unit, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Fatina I Fadel
- Department of Pediatrics, Pediatric Nephrology and Transplantation Unit, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Hesham NAbdel Mooty
- Department of Vascular Surgery, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed El Ghobashy
- Department of Radiodiagnosis, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr M Salem
- Department of Pediatrics, Pediatric Nephrology and Transplantation Unit, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Gamal Fathallah
- Department of Pediatrics, Pediatric Nephrology and Transplantation Unit, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Abobakr Abd Alazem
- Department of Pediatrics, Pediatric Nephrology and Transplantation Unit, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt.
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Ranchin B, Schmitt CP, Warady BA, Hataya H, Jones J, Lalji R, Licht C, Mosca M, Stronach L, Vidal E, Walle JV, Shroff R. Technical requirements and devices available for long-term hemodialysis in children-mind the gap! Pediatr Nephrol 2023:10.1007/s00467-023-06233-0. [PMID: 38141144 DOI: 10.1007/s00467-023-06233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023]
Abstract
Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.
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Affiliation(s)
- Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France.
- Centre de référence des maladies rénales rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron Cedex, France.
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
- Department of Pediatrics, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan
| | - Joanne Jones
- Queensland Children's Hospital, University of Queensland, Brisbane, Australia
| | - Rowena Lalji
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Australia
- Metro South and Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Christoph Licht
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Division of Nephrology and Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Melodie Mosca
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Lynsey Stronach
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Enrico Vidal
- Pediatric Nephrology Unit, Department for Woman and Child's Health, University-Hospital of Padua, Padua, Italy
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
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Reijman MD, Kusters DM, Groothoff JW, Arbeiter K, Dann EJ, de Boer LM, de Ferranti SD, Gallo A, Greber-Platzer S, Hartz J, Hudgins LC, Ibarretxe D, Kayikcioglu M, Klingel R, Kolovou GD, Oh J, Planken RN, Stefanutti C, Taylan C, Wiegman A, Schmitt CP. Clinical practice recommendations on lipoprotein apheresis for children with homozygous familial hypercholesterolemia: an expert consensus statement from ERKNet and ESPN. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.14.23298547. [PMID: 38014132 PMCID: PMC10680892 DOI: 10.1101/2023.11.14.23298547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Homozygous familial hypercholesterolaemia is a life-threatening genetic condition, which causes extremely elevated LDL-C levels and atherosclerotic cardiovascular disease very early in life. It is vital to start effective lipid-lowering treatment from diagnosis onwards. Even with dietary and current multimodal pharmaceutical lipid-lowering therapies, LDL-C treatment goals cannot be achieved in many children. Lipoprotein apheresis is an extracorporeal lipid-lowering treatment, which is well established since three decades, lowering serum LDL-C levels by more than 70% per session. Data on the use of lipoprotein apheresis in children with homozygous familial hypercholesterolaemia mainly consists of case-reports and case-series, precluding strong evidence-based guidelines. We present a consensus statement on lipoprotein apheresis in children based on the current available evidence and opinions from experts in lipoprotein apheresis from over the world. It comprises practical statements regarding the indication, methods, treatment targets and follow-up of lipoprotein apheresis in children with homozygous familial hypercholesterolaemia and on the role of lipoprotein(a) and liver transplantation.
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Affiliation(s)
- M. Doortje Reijman
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, Netherlands
| | - D. Meeike Kusters
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, Netherlands
| | - Jaap W. Groothoff
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, Netherlands
| | - Klaus Arbeiter
- Division of Paediatric Nephrology and Gastroenterology, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Eldad J. Dann
- Blood Bank and apheresis unit Rambam Health care campus, Haifa, Israel
| | - Lotte M. de Boer
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, Netherlands
| | - Sarah D. de Ferranti
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Antonio Gallo
- Sorbonne Université, INSERM, UMR 1166, Lipidology and cardiovascular prevention Unit, Department of Nutrition, APHP, Hôpital Pitié-Salpêtrière F-75013 Paris, France
| | - Susanne Greber-Platzer
- Clinical Division of Paediatric Pulmonology, Allergology and Endocrinology, Department of Paediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Jacob Hartz
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Lisa C. Hudgins
- The Rogosin Institute, Weill Cornell Medical College, New York, New York, USA
| | - Daiana Ibarretxe
- Vascular Medicine and Metabolism Unit (UVASMET), Hospital Universitari Sant Joan; Universitat Rovira i Virgili; Institut Investigació Sanitària Pere Virgili (IISPV)-CERCA, Spain; Centro de Investigación Biomédica en Red en Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Spain
| | - Meral Kayikcioglu
- Department of Cardiology, Medical Faculty, Ege University, 35100 Izmir, Turkey
| | - Reinhard Klingel
- Apheresis Research Institute, Stadtwaldguertel 77, 50935 Cologne, Germany (www.apheresis-research.org)
| | - Genovefa D. Kolovou
- Metropolitan Hospital, Department of Preventive Cardiology. 9, Ethn. Makariou & 1, El. Venizelou, N. Faliro, 185 47, Athens, Greece
| | - Jun Oh
- University Medical Center Hamburg/Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - R. Nils Planken
- Department of Radiology and nuclear medicine, Amsterdam UMC, location AMC, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
- Amsterdam Cardiovascular Sciences, Atherosclerosis & Ischemic Syndromes, Amsterdam, The Netherlands
| | - Claudia Stefanutti
- Department of Molecular Medicine, Lipid Clinic and Atherosclerosis Prevention Centre, ‘Umberto I’ Hospital ‘Sapienza’ University of Rome, I-00161 Rome, Italy
| | - Christina Taylan
- Paediatric Nephrology, Children’s and Adolescents’ Hospital, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Albert Wiegman
- Amsterdam UMC, University of Amsterdam, Department of Paediatrics, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, Netherlands
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
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11
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Roca-Tey R, Ariceta G, Ríos H, Cruz A, Comas J, Tort J. Changes in vascular access profile for pediatric hemodialysis patients over time: A registry-based study from Catalonia. J Vasc Access 2023:11297298231202634. [PMID: 37817674 DOI: 10.1177/11297298231202634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND The criteria for vascular access (VA) selection in pediatric hemodialysis (HD) population has changed over time until the current patient-centered approach using the individualized Life-Plan. We analyzed the type of VA used by incident and prevalent end-stage kidney disease (ESKD) pediatric patients (pts) treated with HD in Catalonia. METHOD Data from the Catalan Renal Registry of ESKD pts under 18 years of age undergoing kidney replacement therapy (KRT) were examined for a 22-year period (1997-2018). RESULTS ESKD children starting KRT through HD decreased progressively from 55.6% (1997-2001) to 38.2% (2012-2018) and, conversely, there was an increase in pts starting KRT by preemptive kidney transplantation (KT) from 28.9% to 42.6% between the same periods (for both comparisons, p = 0.007). Most ESKD pts started HD by fistula (AVF) from 1997 to 2001 (56.5%) but this percentage decreased over time and no AVFs were used to start HD in children from 2012 to 2018. Likewise, the percentage of children starting HD by tunneled catheter increased progressively from 8.7% to 72.2% between the same periods (for both comparisons, p < 0.001). Regarding prevalent ESKD pts, children on HD decreased from 34.9% in 1997 to 4.7% in 2018 and, conversely, pts with a functioning kidney graft increased from 62.8% to 92.4% during the same periods (for both comparisons, p < 0.001). There was a progressive decrease in the percentage of children dialyzed by AVF from 100% in 1997 to 0% in 2018 (p < 0.001). The KT rate increased from 5.4 per million population (pmp) in 1997 to 17.1 pmp in 2018 (p = 0.007). The median time on HD prior to the first KT progressively decreased to 6.6 months (2014-2018). CONCLUSION The high KT rate was a determining factor in choosing the VA type in the incident and prevalent pediatric population treated with HD in Catalonia.
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Affiliation(s)
- Ramon Roca-Tey
- Department of Nephrology, Hospital Universitari Mollet, Fundació Sanitària Mollet, Mollet del Vallès, Barcelona, Spain
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Universitari Vall d' Hebron, Barcelona, Spain
- Department of Pediatrics, Autonomous University of Barcelona, Barcelona, Spain
| | - Héctor Ríos
- Department of Pediatric Nephrology, Hospital Universitari Vall d' Hebron, Barcelona, Spain
| | - Alejandro Cruz
- Department of Pediatric Nephrology, Hospital Universitari Vall d' Hebron, Barcelona, Spain
| | - Jordi Comas
- Organització Catalana de Transplantaments (OCATT), Health Department of Catalonia, Barcelona, Spain
| | - Jaume Tort
- Organització Catalana de Transplantaments (OCATT), Health Department of Catalonia, Barcelona, Spain
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12
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Tsai D, Zam BB, Tongs C, Chiong F, Sajiv C, Pawar B, Ashok A, Cooper BP, Tong SYC, Janson S, Wallis SC, Roberts JA, Parker SL. Validating a novel three-times-weekly post-hemodialysis ceftriaxone regimen in infected Indigenous Australian patients-a population pharmacokinetic study. J Antimicrob Chemother 2023:dkad190. [PMID: 37367723 PMCID: PMC10393936 DOI: 10.1093/jac/dkad190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
OBJECTIVES To describe the total and unbound population pharmacokinetics of a 2 g three-times-weekly post-dialysis ceftriaxone regimen in Indigenous Australian patients requiring hemodialysis. METHODS A pharmacokinetic study was carried out in the dialysis unit of a remote Australian hospital. Adult Indigenous patients on intermittent hemodialysis (using a high-flux dialyzer) and treated with a 2 g three-times-weekly ceftriaxone regimen were recruited. Plasma samples were serially collected over two dosing intervals and assayed using validated methodology. Population pharmacokinetic analysis and Monte Carlo simulations were performed using Pmetrics in R. The probability of pharmacokinetic/pharmacodynamic target attainment (unbound trough concentrations ≥1 mg/L) and toxicity [trough concentrations (total) ≥100 mg/L] were simulated for various dosing strategies. RESULTS Total and unbound concentrations were measured in 122 plasma samples collected from 16 patients (13 female) with median age 57 years. A two-compartment model including protein-binding adequately described the data, with serum bilirubin concentrations associated (inversely) with ceftriaxone clearance. The 2 g three-times-weekly regimen achieved 98% probability to maintain unbound ceftriaxone concentrations ≥1 mg/L for a serum bilirubin of 5 µmol/L. Incremental accumulation of ceftriaxone was observed in those with bilirubin concentrations >5 µmol/L. Three-times-weekly regimens were less probable to achieve toxic exposures compared with once-daily regimens. Ceftriaxone clearance was increased by >10-fold during dialysis. CONCLUSIONS A novel 2 g three-times-weekly post-dialysis ceftriaxone regimen can be recommended for a bacterial infection with an MIC ≤1 mg/L. A 1 g three-times-weekly post-dialysis regimen is recommended for those with serum bilirubin ≥10 µmol/L. Administration of ceftriaxone during dialysis is not recommended.
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Affiliation(s)
- Danny Tsai
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
- Pharmacy Department, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Betty B Zam
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
| | - Carleigh Tongs
- Northern Territory Medical Program, College of Medicine and Public Health, Flinders University, Darwin, NT, Australia
| | - Fabian Chiong
- Department of Medicine, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Cherian Sajiv
- Department of Nephrology, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Basant Pawar
- Department of Nephrology, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Aadith Ashok
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
| | - Brynley P Cooper
- Pharmacy Department, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Sonja Janson
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia
| | - Steven C Wallis
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Suzanne L Parker
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
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13
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Ahn YH. Optimal hemodialysis treatment for pediatric kidney failure patients. Clin Exp Pediatr 2023; 66:125-126. [PMID: 36789490 PMCID: PMC9989721 DOI: 10.3345/cep.2022.01431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/17/2022] [Indexed: 02/16/2023] Open
Affiliation(s)
- Yo Han Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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14
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Ramírez-Senent B, Aragoncillo I, Ligero JM. Impact of Isometric Exercise in Adolescents With End Stage Kidney Disease and Unsuitable Vessels For An Autologous Arteriovenous Fistula. Vasc Endovascular Surg 2023; 57:149-153. [PMID: 36194486 DOI: 10.1177/15385744221131426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Despite the lack of calcification, to perform a native Arteriovenous Fistula (AVF) in young patients may pose a challenge due to small vessel diameter. We report a case series with no options of AVF in which vessel caliber improvement after isometric exercise allowed for radiocephalic fistula creation in all of them. METHODS Since 2017 to 2019, four patients were referred to our unit to create an AVF. Following a first assessment with physical examination and doppler ultrasound, none of them were eligible for AVF performance due to small vessel caliber. Once they were considered unsuitable for it, they started an isometric exercise program. RESULTS Age ranged from 13 to 19 years. There were three males and one female. Two were in predialysis and two in hemodialysis program. Initial diameters of the forearm cephalic vein and the radial artery respectively were: case A < 1.5/2.3 mm, case B 1.5/1.6 mm, case C < 1.5/1.6 mm and case D 2.1/1.3 mm. Median duration of exercise program was 13 weeks (range 5-23). Post-exercise vessel diameters were: case A 2.7/2.3 mm, case B 2.5/2 mm, case C 2.8/1.8 mm and case D 2.7/2 mm. Radiocephalic AVF were performed in the four cases. After a median follow up of 19 months (range 9-30 months), 75% of patients required further interventions but all of them had a functional AVF. CONCLUSIONS In these four cases isometric preoperative exercise allowed the creation of AVF. Without the improvement in vessel diameter observed afterwards, all of them would have been rejected for AVF performance. Despite the high rate of adjunctive interventions needed, given the safety of the program and the potential risks of Central Venous Catheters, we consider it a valuable option.
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Affiliation(s)
- Belén Ramírez-Senent
- Department of Vascular Surgery, 16483Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Department of Vascular Surgery, 83011Hospital de Navarra, Madrid, Spain
| | - Inés Aragoncillo
- Department of Nephrology, 16483Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Manuel Ligero
- Department of Vascular Surgery, 16483Hospital General Universitario Gregorio Marañón, Madrid, Spain
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15
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Garza B, Geer J, Swartz SJ, Srivaths P, Huynh TTT, Brewer ED. Good outcomes for arteriovenous fistula with buttonhole cannulation for chronic hemodialysis in children and adolescents. Pediatr Nephrol 2023; 38:509-517. [PMID: 35511295 DOI: 10.1007/s00467-022-05580-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/17/2022] [Accepted: 04/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Arteriovenous fistula (AVF) is the preferred access for chronic hemodialysis (HD) in children and adolescents, but central venous catheter use is still high. METHODS Retrospective chart review of children and adolescents with AVF created between January 2003 and December 2015 was performed to assess primary failure (PF), maturation time, functional primary and functional cumulative patency, and potential risk factors for AVF dysfunction. RESULTS Ninety-nine AVF were created in 79 patients (54% male; 7-24 years; 16-147 kg) by experienced surgeons. Duplex ultrasonography vein mapping was used to assist with site selection. PF occurred in 17 AVF (17%) in 14 patients. Patient age, gender, ethnicity, underlying disease, time on dialysis, and AVF site were not associated with PF or patency. Coagulation abnormality was positively associated with PF (p = 0.03). Function was achieved in 82 AVF (83%) in 77 patients (97%). Median maturation time was 83 days (range 32-271). AVF were accessed via buttonholes. Functional primary patency was 95%, 84%, and 53% at 1, 2, and 5 years. Overall 1- and 2-year functional cumulative patency was 95%, but lower for small patients 16-30 kg (88%) and those greater than 80 kg (91%). The 5-year patency rate was 80%, but significantly lower for 16-30 kg (59%) and greater than 80 kg (55%). Risk analysis showed significantly better patency for 31-45 kg and 46-80 kg groups (p < 0.01), non-obese BMI (p = 0.01), and buttonhole self-cannulation (p = 0.03). CONCLUSIONS This study provides more information about successful AVF with buttonhole cannulation in pediatric hemodialysis patients lending additional support for AVF use in pediatrics. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Brittany Garza
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA.
| | - Jessica Geer
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA
| | - Tam T T Huynh
- Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Eileen D Brewer
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA
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16
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The effects of hospital and dialysis unit characteristics on hospitalizations for access-related complications among children on maintenance dialysis: a European, multicenter, observational, cross-sectional study. Pediatr Nephrol 2023:10.1007/s00467-022-05842-5. [PMID: 36595069 DOI: 10.1007/s00467-022-05842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Previous studies investigating hospitalizations in dialysis patients have focused primarily on patient-centered factors. We analyzed the impact of hospital and dialysis unit characteristics on pediatric dialysis patients' hospitalizations for access-related complications (ARCs). METHODS This cross-sectional study involved 102 hemodialysis (HD) and 163 peritoneal dialysis (PD) patients. Data between July 2017 and July 2018 were analyzed. RESULTS Children's hospitals (CHs) had more pediatric nephrologists and longer PD experience (years) than general hospitals (GHs) (p = 0.026 and p = 0.023, respectively). A total of 53% of automated PD (APD) and 6% of continuous ambulatory PD (CAPD) patients were in CHs (p < 0.001). Ninety-three percent of APD and 69% of CAPD patients were treated in pediatric-specific PD units (p = 0.001). CHs had a higher prevalence in providing hemodiafiltration (HDF) than GHs (83% vs. 30%). Ninety-seven percent of HDF vs. 66% for conventional HD (cHD) patients, and 94% of patients with arteriovenous fistula (AVF) vs. 70% of those with central venous catheters (CVC), were dialyzed in pediatric-specific HD units (p = 0.001 and p = 0.016, respectively). Eighty patients (51 PD and 29 HD) had 135 (84 PD, 51 HD) hospitalizations. CAPD was an independent risk factor for hospitalizations for infectious ARCs (I-ARCs) (p = 0.009), and a health center's PD experience negatively correlated with CAPD patient hospitalizations for I-ARCs (p = 0.041). cHD and dialyzing in combined HD units significantly increased hospitalization risk for non-infectious (NI-)ARCs (p = 0.044 and p = 0.017, respectively). CONCLUSIONS CHs and pediatric-specific dialysis units have higher prevalence of APD and HDF use. Hospitalizations for I-ARCs in CAPD are lower in centers with longer PD experience, and pediatric HD units are associated with fewer hospitalizations due to NI-ARCs. A higher resolution version of the Graphical abstract is available as Supplementary information.
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17
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Bruno C, Moumneh R, Sauvage E, Stronach L, Waters K, Simcock I, Arthurs O, Schievano S, Capelli C, Shroff R. Central Venous Catheter Malfunction in Children: A Bioengineering Approach. Clin J Am Soc Nephrol 2022; 17:1382-1384. [PMID: 35817475 PMCID: PMC9625107 DOI: 10.2215/cjn.01470222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Claudia Bruno
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Rayan Moumneh
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Emilie Sauvage
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Lynsey Stronach
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Kathryn Waters
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Ian Simcock
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- National Institute for Health and Care Research Great Ormond Street Hospital Biomedical Research Centre, London, United Kingdom
| | - Owen Arthurs
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Silvia Schievano
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Claudio Capelli
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Rukshana Shroff
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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18
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Ruebner RL, De Souza HG, Richardson T, Bedri B, Marsenic O, Iorember F, Warejko JK, Warady BA, Neu AM. Epidemiology and Risk Factors for Hemodialysis Access-Associated Infections in Children: A Prospective Cohort Study From the SCOPE Collaborative. Am J Kidney Dis 2022; 80:186-195.e1. [PMID: 34979159 DOI: 10.1053/j.ajkd.2021.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/04/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Infections cause significant morbidity and mortality for children receiving maintenance hemodialysis (HD). The Standardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a quality-improvement initiative aimed at reducing dialysis-associated infections by implementing standardized care practices. This study describes patient-level risk factors for catheter-associated bloodstream infections (CA-BSIs) and examines the association between dialysis center-level compliance with standardized practices and risk of CA-BSI. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Children enrolled in SCOPE between June 2013 and July 2019. EXPOSURES Data were collected on patient characteristics and center-level compliance with HD catheter care practices across the study period. Centers were categorized as consistent, dynamic (improved compliance over the study period), or inconsistent performers based on frequency of compliance audit submission and changes in compliance with HD care practices over time. OUTCOME CA-BSIs. ANALYTICAL APPROACH Generalized linear mixed models were used to evaluate (1) patient-level risk factors for CA-BSI and (2) associations between change in center-level compliance and CA-BSIs. RESULTS The cohort included 1,277 children from 35 pediatric dialysis centers; 1,018 (79.7%) had a catheter and 259 (20.3%) had an arteriovenous fistula or graft. Among children with a catheter, mupirocin use at the catheter exit site was associated with an increased rate of CA-BSIs (rate ratio [RR], 4.45; P = 0.004); the use of no antibiotic agent at the catheter exit site was a risk factor of borderline statistical significance (RR, 1.79; P = 0.05). Overall median compliance with HD catheter care practices was 87.5% (IQR, 77.3%-94.0%). Dynamic performing centers showed a significant decrease in CA-BSI rates over time (from 2.71 to 0.71 per 100 patient-months; RR, 0.98; P < 0.001), whereas no significant change in CA-BSI rates was detected among consistent or inconsistent performers. LIMITATIONS Lack of data on adherence to HD care practices on the individual patient level. CONCLUSIONS Improvement in compliance with standardized HD care practices over time may lead to a reduction in dialysis-associated infections.
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Affiliation(s)
- Rebecca L Ruebner
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | | | - Badreldin Bedri
- Division of Pediatric Nephrology, Cook Children's Hospital, Fort Worth, Texas
| | - Olivera Marsenic
- Division of Pediatric Nephrology, Stanford University School of Medicine, Stanford, California
| | - Franca Iorember
- Division of Pediatric Nephrology, Baylor College of Medicine San Antonio, San Antonio, Texas
| | - Jillian K Warejko
- Section of Pediatric Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Alicia M Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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19
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Kamath N, Naik N, Iyengar A. Clinical profile and outcome of arterio-venous fistulae in children on maintenance hemodialysis belonging to a low resource setting. J Vasc Surg 2022; 76:1699-1703. [PMID: 35810952 DOI: 10.1016/j.jvs.2022.06.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/09/2022] [Accepted: 06/19/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Nivedita Kamath
- Associate Professor, Department of Pediatric Nephrology, St John's Medical College Hospital, Bengaluru, India.
| | - Naveen Naik
- Renal Dialysis Technologist, Department of Pediatric Nephrology, St John's Medical College Hospital, Bengaluru, India
| | - Arpana Iyengar
- Professor, Department of Pediatric Nephrology, St John's Medical College Hospital, Bengaluru, India
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20
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Bruno C, Sauvage E, Simcock I, Redaelli A, Schievano S, Shroff R, Capelli C. Computational investigation of the haemodynamics shows criticalities of central venous lines used for chronic haemodialysis in children. Front Pediatr 2022; 10:1055212. [PMID: 36389366 PMCID: PMC9659647 DOI: 10.3389/fped.2022.1055212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/10/2022] [Indexed: 12/03/2022] Open
Abstract
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).
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Affiliation(s)
- Claudia Bruno
- Institute of Child Health, University College London, London, United Kingdom
| | - Emilie Sauvage
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Ian Simcock
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Silvia Schievano
- Institute of Cardiovascular Science, University College London, London, United Kingdom.,Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Rukshana Shroff
- Institute of Child Health, University College London, London, United Kingdom.,Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Claudio Capelli
- Institute of Cardiovascular Science, University College London, London, United Kingdom.,Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
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21
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Outcomes of arteriovenous fistula for hemodialysis in pediatric age group. Ann Med Surg (Lond) 2021; 72:103100. [PMID: 34917348 PMCID: PMC8646130 DOI: 10.1016/j.amsu.2021.103100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The feasibility of arteriovenous fistula (AVF) creation in pediatric patients has long been documented, but few studies have evaluated the forms and long-term outcomes. The aim of this article is to highlight the types, techniques and outcomes of AVFs in pediatric age group. Methods This is multi-center, retrospective, single cohort study, including all the cases of pediatric (less than 18 year old) cases underwent AVF creation during four years (2015–2019). The following data were obtained from the patients' medical records and analyzed; socio-demographics, etiology of renal failure (RF), history of dialysis and transplantation, type and site of AVF, the outcomes and complications. Results The study included 108 patients, 89 patients (82.4%) were female. The mean age was 13 years. The most common cause of RF was the urological causes which were found in 34 cases (31.5%), followed by nephrotic syndrome (32 cases, 29.6%), glomerulonephritis (27 cases, 25%), and polycystic kidney disease (12 cases, 11.1%). The decision for choosing access site was performed only by clinical examination in 96 patients (88.9%) while duplex ultrasound was requested for 12 cases (11.1%). The operation was done under local anesthesia in 81 cases (75%) and general anesthesia in 27 cases (25%). The procedure was performed in the wrist in 58 cases (53.7%) and in cubital fossa in 50 cases (46.2%). The most common early complication was hematoma (12 cases, 11.1%), followed by ecchymosis (10 cases, 9.3%), infection (8, 7.4%), seroma (4, 3.7%) and thrombosis (3, 2.8%). The one-year primary patency rate was found in 95 patients (88%) and two-year patency rate in 86 patients (79.6%). Conclusion Native AVF in pediatric is the first choice dialysis access even in pediatric population. Radiocephalic in the non-dominant hand is the most preferred site. The feasibility of AVF creation in pediatric patients has long been documented. Few studies have evaluated the forms and long-term outcomes. Physical examination is an effective method for determining the proper site for access creation. The aim of this article is to highlight the types, techniques and outcome of AVFs in pediatric age group.
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22
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Abstract
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.
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23
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Preka E, Shroff R, Stronach L, Calder F, Stefanidis CJ. Update on the creation and maintenance of arteriovenous fistulas for haemodialysis in children. Pediatr Nephrol 2021; 36:1739-1749. [PMID: 33063165 DOI: 10.1007/s00467-020-04746-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/02/2020] [Accepted: 08/26/2020] [Indexed: 11/27/2022]
Abstract
Arteriovenous fistulas (AVFs) are widely used for haemodialysis (HD) in adults with stage 5 chronic kidney disease (CKD 5) and are generally considered the best form of vascular access (VA). The 'Fistula First' initiative in 2003 helped to change the culture of VA in adults. However, this cultural change has not yet been adopted in children despite the fact that a functioning AVF is associated with lower complication rates and longer access survival than a central venous line (CVL). For children with CKD 5, especially when kidney failure starts early in life, there is a risk that all VA options will be exhausted. Therefore, it is essential to develop long-term strategies for optimal VA creation and maintenance. Whilst AVFs are the preferred VA in the paediatric population on chronic HD, they may not be suitable for every child. Recent guidelines and observational data in the paediatric CKD 5 population recommend switching from a 'Catheter First' to 'Catheter Last' approach. In this review, recent evidence is summarized in order to promote change in current practices.
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Affiliation(s)
- Evgenia Preka
- Southampton Children's Hospital and University of Southampton School of Medicine, Tremona Road, Southampton, SO16 6YD, UK.
| | - Rukshana Shroff
- UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Lynsey Stronach
- UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Francis Calder
- UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK.,Evelina London Children's Hospital NHS Foundation Trust, London, UK
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24
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Putz FJ, Pfister K, Bergler T, Banas MC, Jung EM, Banas B, Schierling W. Sonographic 3-D Power Doppler Imaging Enhances Rapid Assessment of Morphologic and Pathologic Arteriovenous Fistula Variations. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1484-1494. [PMID: 33757696 DOI: 10.1016/j.ultrasmedbio.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/13/2021] [Accepted: 02/17/2021] [Indexed: 06/12/2023]
Abstract
Early detection of pathologic variations in an arteriovenous fistula (AVF) is essential for preventing fistula dysfunction in individuals undergoing hemodialysis. This study aimed to evaluate the clinical applicability of 3-D tomographic ultrasound (tUS) for rapid and simple visualization of AVF morphology and pathology. We assessed 53 AVFs in 50 consecutive patients using 3-D tUS including secondary, blinded reading. For all examinations, a high-end ultrasound (US) device was used with linear probe, attached to a tUS system to allow freehand 3-D scanning. Participants were examined by 2-D US and 3-D tUS with different raw data (B-mode, power Doppler, B-flow). Additional angiography was available for 15 participants with scheduled interventions. In all participants, 3-D tUS allowed a 3-D representation of AVFs in angiographic-like images with good image quality. The 2-D US assessment took 7.9 ± 4.0 min. A 3-D power Doppler scan required, on average, 1.4 ± 0.6 min. Diagnostic accuracy of blinded reading for pathologies was high (86.8% for aneurysms and 79.2% for stenoses). Bland-Altman plots showed an excellent correlation of 3-D tUS with 2-D US and angiography. 3-D tUS is an easily and rapidly applicable method for visualizing morphologic and pathologic AVF variations. Color-coded 3-D reconstruction of power Doppler data simplifies detection of perfused aneurysms and stenoses.
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Affiliation(s)
- Franz Josef Putz
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany.
| | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Miriam C Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | | | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Wilma Schierling
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
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25
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Singh NS, Grimes J, Gregg GK, Nau AE, Rivard DC, Fields M, Flaucher N, Sherman AK, Williams MU, Wiley KJ, Kerwin K, Warady BA. "Save the Vein" Initiative in Children With CKD: A Quality Improvement Study. Am J Kidney Dis 2021; 78:96-102.e1. [PMID: 33421455 DOI: 10.1053/j.ajkd.2020.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/14/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The preferred vascular access for hemodialysis recipients is an arteriovenous fistula in the nondominant arm. Prior placement of a peripheral intravenous (PIV) catheter can lead to vascular injury and limit options for arteriovenous fistula creation, a particular problem for children, who may need hemodialysis for their entire lifetime. We instituted an initiative to increase the frequency of PIV catheter placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease (CKD). STUDY DESIGN Quality improvement initiative. SETTING & PARTICIPANTS Children with CKD stage 3-5, receiving dialysis, and/or following kidney transplantation who were hospitalized at one children's hospital between September 2018 and August 2020. QUALITY IMPROVEMENT ACTIVITIES Retrospective data on PIV catheter location for patients from January 1 to June 30, 2017, served as baseline data. Quality improvement activities consisted of: 1) education of the multidisciplinary treatment team, patients, and parents regarding importance of vein preservation; 2) placement of individualized notes in the electronic medical record identifying the preferred arm for PIV catheter placement; 3) use of "restricted extremity" arm bands; and 4) vascular access team participation to minimize attempts for PIV catheter placement. OUTCOME Monthly compliance with placement of PIV catheters in dominant arms. ANALYTICAL APPROACH Location of PIV catheter placements were determined monthly and used to create run charts describing compliance. RESULTS At baseline and before institution of this initiative, 34 of 72 (47%) PIV catheters were placed in patients' dominant arms, with only 2 of 8 (25%) PIV catheters placed in the dominant arm for children aged<5 years. After instituting the initiative, 345 of 371 (93%) PIV catheters were placed in the dominant arm of 93 children; in children aged<5 years, 58 of 62 (94%) PIV catheters were placed in the dominant arm. Only 38 of 371 (10%) PIV catheters were placed in the antecubital vein. LIMITATIONS Single-center study. CONCLUSIONS Education regarding the importance of vein preservation, along with implementation of a standardized process for identifying children for whom vein preservation is important, can help direct PIV catheter placement and potentially preserve vasculature in pediatric patients with CKD.
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Affiliation(s)
- Nisha S Singh
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO
| | - JoLynn Grimes
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO
| | - Gina K Gregg
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO
| | - Amy E Nau
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO
| | - Douglas C Rivard
- Department of Radiology, Children's Mercy Kansas City, Kansas City, MO
| | - Moriah Fields
- Vascular Access Team, Children's Mercy Kansas City, Kansas City, MO
| | | | - Ashley K Sherman
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO
| | - Maria U Williams
- Department of Nursing, Children's Mercy Kansas City, Kansas City, MO
| | - Kaylene J Wiley
- Department of Nursing, Children's Mercy Kansas City, Kansas City, MO
| | - Kristen Kerwin
- Department of Nursing, Children's Mercy Kansas City, Kansas City, MO
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO.
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26
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Garcia-Nicoletti M, Sinha MD, Savis A, Adalat S, Karunanithy N, Calder F. Silent and dangerous: catheter-associated right atrial thrombus (CRAT) in children on chronic haemodialysis. Pediatr Nephrol 2021; 36:1245-1254. [PMID: 33125532 PMCID: PMC8009777 DOI: 10.1007/s00467-020-04743-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/05/2020] [Accepted: 08/24/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Catheter-associated right atrial thrombus (CRAT) is a recognised complication of central venous catheter (CVC) use for haemodialysis (HD) patients. METHODS This was a single-centre retrospective longitudinal observational study of consecutive children aged 6 months-18 years over a 7-year period receiving in-centre chronic HD. Echocardiograms as per routine cardiac surveillance were performed 6 months or earlier given clinical concerns. RESULTS Sixty-five children, 36 boys (55.4%), median (IQR) age 11.8 (5.3, 14.7) years, received HD for kidney failure with replacement therapy (KFRT). Initial modality was HD in 45 (69.2%), with CVC as initial access in 42 (93.3%) and AVF in 3 (6.7%); in the remaining 20 (30.8%) patients PD was the initial modality before switching to HD. Seven of 65 (10.8%) developed CRAT at median 2 (0.8, 8.4) months from CVC insertion, with one CRAT detected 3 days following insertion. One child had 2 episodes of CRAT and one additionally thrombosed their AVF. No patient had an underlying primary kidney disease associated with a pro-thrombotic state. Those with CRAT were younger, had more frequent CVC change and received dialysis for longer duration compared to those with no CRAT. Six episodes of CRAT (75%) received anticoagulation therapy. Infective complications were observed in 25% and catheter malfunction in 50%. Five CRAT episodes (62.5%) resulted in CVC loss. One patient died after a haemorrhagic complication of anticoagulation and sepsis, and another developed life-threatening superior vena cava obstruction syndrome. Overall mortality 14% (1/7). CONCLUSIONS This is the first report of CRAT in a paediatric HD population. There was ~ 11% incidence of CRAT in patients receiving chronic HD detected by surveillance echocardiography. Although frequently asymptomatic, CRAT is associated with serious sequelae. Anticoagulation and surveillance with expert echocardiography remain mainstays of management. Graphical abstract.
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Affiliation(s)
| | - Manish D. Sinha
- Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, SE1 7EH UK ,Kings College London, London, UK
| | - Alexandra Savis
- Department of Paediatric Cardiology, Evelina London Children’s Hospital, London, UK
| | - Shazia Adalat
- Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, SE1 7EH UK
| | - Narayan Karunanithy
- Department of Intervention Radiology, Evelina London Children’s Hospital, London, UK ,School of Biomedical Engineering & Imaging Sciences, King’s College London, London, UK
| | - Francis Calder
- Department of Paediatric Nephrology, Evelina London Children's Hospital, London, SE1 7EH, UK. .,Department of Paediatric Transplantation, Evelina London Children's Hospital, London, UK.
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27
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Cardiovascular Outcome of Pediatric Patients With Bi-Allelic (Homozygous) Familial Hypercholesterolemia Before and After Initiation of Multimodal Lipid Lowering Therapy Including Lipoprotein Apheresis. Am J Cardiol 2020; 136:38-48. [PMID: 32946862 DOI: 10.1016/j.amjcard.2020.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/14/2022]
Abstract
Twenty-four patients with bi-allelic familial hypercholesterolemia commencing chronic lipoprotein apheresis (LA) at a mean age of 8.5 ± 3.1 years were analysed retrospectively and in part prospectively with a mean follow-up of 17.2 ± 5.6 years. Mean age at diagnosis was 6.3 ± 3.4 years. Untreated mean LDL-C concentrations were 752 mg/dl ± 193 mg/dl (19.5 mmol/l ± 5.0 mmol/l). Multimodal lipid lowering therapy including LA resulted in a mean LDL-C concentration of 184 mg/dl (4.8 mmol/l), which represents a 75.5% mean reduction. Proprotein convertase subtilisin/kexin type 9-antibodies contributed in 3 patients to LDL-C lowering with 5 patients remaining to be tested. After commencing chronic LA, 16 patients (67%) remained clinically stable with only subclinical findings of atherosclerotic cardiovascular disease (ASCVD), and neither cardiovascular events, nor need for vascular interventions or surgery. In 19 patients (79%), pathologic findings were detected at the aortic valve (AV), which in the majority were mild. AV replacement was required in 2 patients. Mean Lipoprotein(a) concentration was 42.4 mg/dl, 38% had >50 mg/dl. There was no overt correlation of AV pathologies with other ASCVD complications, or Lipoprotein(a) concentration. Physicochemical elimination of LDL particles by LA appears indispensable for patients with bi-allelic familial hypercholesterolemia and severe hypercholesterolemia to maximize the reduction of LDL-C. In conclusion, in this rare patient group regular assessment of both the AV, as well as all arteries accessible by ultrasound should be performed to adjust the intensity of multimodal lipid lowering therapy with the goal to prevent ASCVD events and aortic surgery.
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28
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Raina R, Joshi H, Chakraborty R, Sethi SK. Challenges of long-term vascular access in pediatric hemodialysis: Recommendations for practitioners. Hemodial Int 2020; 25:3-11. [PMID: 33073521 DOI: 10.1111/hdi.12868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/03/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Hirva Joshi
- Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Ronith Chakraborty
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, Ohio, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
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29
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Onder AM, Flynn JT, Billings AA, Deng F, DeFreitas M, Katsoufis C, Grinsell MM, Patterson L, Jetton J, Fathallah-Shaykh S, Ranch D, Aviles D, Copelovitch L, Ellis E, Chadha V, Elmaghrabi A, Lin JJ, Butani L, Haddad M, Marsenic O, Brakeman P, Quigley R, Shin HS, Garro R, Liu H, Rahimikollu J, Raina R, Langman CB, Wood E. Predictors of time to first cannulation for arteriovenous fistula in pediatric hemodialysis patients: Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 2020; 35:287-295. [PMID: 31696356 DOI: 10.1007/s00467-019-04396-3] [Citation(s) in RCA: 5] [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: 06/11/2019] [Revised: 09/16/2019] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Permanent vascular access (PVA) is preferred for long-term hemodialysis. Arteriovenous fistulae (AVF) have the best patency and the lowest complication rates compared to arteriovenous grafts (AVG) and tunneled cuffed catheters (TCC). However, AVF need time to mature. This study aimed to investigate predictors of time to first cannulation for AVF in pediatric hemodialysis patients. METHODS Data on first AVF and AVG of patients at 20 pediatric dialysis centers were collected retrospectively, including demographics, clinical information, dialysis markers, and surgical data. Statistical modeling was used to investigate predictors of outcome. RESULTS First PVA was created in 117 children: 103 (88%) AVF and 14 (12%) AVG. Mean age at AVF creation was 15.0 ± 3.3 years. AVF successfully matured in 89 children (86.4%), and mean time to first cannulation was 3.6 ± 2.5 months. In a multivariable regression model, study center, age, duration of non-permanent vascular access (NPVA), and Kt/V at AVF creation predicted time to first cannulation, with study center as the strongest predictor (p < 0.01). Time to first cannulation decreased with increasing age (p = 0.03) and with increasing Kt/V (p = 0.01), and increased with duration of NPVA (p = 0.03). Secondary failure occurred in 10 AVF (11.8%). Time to first cannulation did not predict secondary failure (p = 0.29), but longer time to first cannulation tended towards longer secondary patency (p = 0.06). CONCLUSIONS Study center is the strongest predictor of time to first cannulation for AVF and deserves further investigation. Time to first cannulation is significantly shorter in older children, with more efficient dialysis treatments, and increases with longer NPVA duration.
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Affiliation(s)
- Ali Mirza Onder
- Division of Pediatric Nephrology, Le Bonheur Children's Hospital, University of Tennessee, School of Medicine, Memphis, TN, USA.
- Division of Pediatric Nephrology, Batson Children's Hospital of Mississippi , University of Mississippi Medical Center, Jackson, MS, USA.
| | - Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Fang Deng
- Kidney Diseases Division, Feinberg School of Medicine, Northwestern University and the Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marissa DeFreitas
- Department of Pediatrics, Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami Leonard M Miller School of Medicine, Miami, FL, USA
| | - Chryso Katsoufis
- Department of Pediatrics, Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami Leonard M Miller School of Medicine, Miami, FL, USA
| | - Matthew M Grinsell
- Division of Pediatric Nephrology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Larry Patterson
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
| | - Jennifer Jetton
- Division of Nephrology, Dialysis and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Sahar Fathallah-Shaykh
- Division of Pediatric Nephrology, Children's of Alabama, University of Alabama, Birmingham, AL, USA
| | - Daniel Ranch
- Division of Pediatric Nephrology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Diego Aviles
- Division of Pediatric Nephrology, Children's Hospital New Orleans, LSU Heath School of Medicine, New Orleans, LA, USA
| | - Lawrence Copelovitch
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eileen Ellis
- Division of Pediatric Nephrology, Arkansas Children's Hospital, Little Rock, AR, 72202, USA
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Ayah Elmaghrabi
- Division of Pediatric Nephrology, Children's Medical Center Dallas, UT Southwestern, Dallas, TX, USA
| | - Jen-Jar Lin
- Division of Pediatric Nephrology, Brenner Children's Hospital, Wake Forest University, Winston Salem, NC, USA
| | - Lavjay Butani
- Division of Pediatric Nephrology, UC Davis Children's Hospital, Sacramento, CA, USA
| | - Maha Haddad
- Division of Pediatric Nephrology, UC Davis Children's Hospital, Sacramento, CA, USA
| | - Olivera Marsenic
- Division of Pediatric Nephrology, Yale New Haven Children's Hospital, Yale University School of Medicine, New Haven, CT, 06504, USA
| | - Paul Brakeman
- Division of Pediatric Nephrology, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Raymond Quigley
- Division of Pediatric Nephrology, Children's Medical Center Dallas, UT Southwestern, Dallas, TX, USA
| | - H Stella Shin
- Division of Pediatric Nephrology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Rouba Garro
- Division of Pediatric Nephrology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Hui Liu
- Division of General Academic Pediatrics, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Javad Rahimikollu
- Department of Statistics, West Virginia University, Morgantown, WV, USA
| | - Rupesh Raina
- Division of Pediatric Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Craig B Langman
- Kidney Diseases Division, Feinberg School of Medicine, Northwestern University and the Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Ellen Wood
- Department of Pediatrics, Division of Pediatric Nephrology, SSM Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, MO, USA
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30
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Marsenic O, Rodean J, Richardson T, Swartz S, Claes D, Day JC, Warady B, Neu A. Tunneled hemodialysis catheter care practices and blood stream infection rate in children: results from the SCOPE collaborative. Pediatr Nephrol 2020; 35:135-143. [PMID: 31654224 DOI: 10.1007/s00467-019-04384-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE. METHODS Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques. RESULTS Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001). CONCLUSIONS Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.
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MESH Headings
- Adolescent
- Catheter-Related Infections/epidemiology
- Catheter-Related Infections/etiology
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/standards
- Catheterization, Central Venous/statistics & numerical data
- Central Venous Catheters/adverse effects
- Central Venous Catheters/standards
- Central Venous Catheters/statistics & numerical data
- Child
- Child, Preschool
- Female
- Guideline Adherence/statistics & numerical data
- Humans
- Infant
- Infant, Newborn
- Intersectoral Collaboration
- Kidney Failure, Chronic/therapy
- Male
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/organization & administration
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Program Evaluation
- Prospective Studies
- Quality Improvement/organization & administration
- Renal Dialysis/adverse effects
- Renal Dialysis/instrumentation
- Renal Dialysis/standards
- Renal Dialysis/statistics & numerical data
- Sepsis/epidemiology
- Sepsis/etiology
- Standard of Care/organization & administration
- Standard of Care/statistics & numerical data
- Young Adult
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Affiliation(s)
- Olivera Marsenic
- Pediatric Nephrology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | | | | | | | - Donna Claes
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | | | - Alicia Neu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Karava V, Kwon T, Franco G, Georges D, Macher MA, Hogan J. Ultrasound dilution and thermodilution versus color Doppler ultrasound for arteriovenous fistula assessment in children on hemodialysis. Pediatr Nephrol 2019; 34:2381-2387. [PMID: 31324981 DOI: 10.1007/s00467-019-04297-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 04/26/2019] [Accepted: 06/13/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study is aimed at comparing ultrasound dilution (UD) and thermodilution (TD) with color Doppler ultrasound (CDU) for arteriovenous fistula (AVF) assessment in children on hemodialysis (HD). MATERIAL AND METHODS All patients were dialysed with the Fresenius 5008 HD machine. UD was performed using the Transonic device. The two methods were compared with CDU performed on a non-HD day. AVF flow rate was expressed as ml/min/1.73 m2. RESULTS Sixteen measurements of AVF flow rate and recirculation with UD and TD were compared with CDU in 16 patients with a median weight of 39 kg. Both UD and TD overestimated AVF flow rate when compared with CDU (+437 (95% CI + 200, + 674) and + 476 (95% CI + 80, + 871) ml/min/1.73 m2 for UD and TD, respectively). CDU flow rate was significantly correlated to UD flow rate (r2 = 0.761, p < 0.001), but not to TD flow rate (r2 = 0.164, p = 0.120). Although recirculation in all AVF was estimated to be 0% and < 15% with UD and TD, respectively, 7 significant stenoses were diagnosed by CDU. AVF with stenosis had lower flow rates when measured by CDU, UD or TD, but only CDU measurements reached statistical significance (p = 0.008, p = 0.142 and p = 0.174, respectively). CONCLUSION UD and TD overestimate AVF flow rate when compared with CDU, which is the most reliable non-invasive method for screening vascular access for stenosis. UD seems more accurate than TD for AVF flow rate assessment. Recirculation via UD or TD should not be used for early screening of AVF stenosis in children on HD.
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Affiliation(s)
- Vasiliki Karava
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France.
| | - Theresa Kwon
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | | | - Deschenes Georges
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Marie-Alice Macher
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Julien Hogan
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
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