Advances in renal replacement therapy as a bridge to renal transplantation

Surgical complications after peritoneal dialysis catheter implantation depend on children's weight

BACKGROUND

Surgical complications are estimated to be as high as 30%-40% during the first 8 weeks after implantation of peritoneal dialysis (PD) catheters.

METHODS

70 PD catheters which were implanted by transplant surgeons in 61 children (median age 3.3years, range 0.01-15.5years, 31 boys and 30 girls) in 2009-2014 were retrospectively reviewed. The incidence of complications and revisions during the first 6months after implantation was analyzed depending on children's weight and diagnosis.

RESULTS

17 out of 70 catheters needed a surgical revision within 6months after implantation (24.3%). Peritonitis was the most common complication affecting 18.6% of peritoneal dialysis catheters followed by obstruction and dislocation, which it occurred in 9 (12.9%) and 7 (10%) catheters, respectively. Leakage (n=5) only occurred in children with a weight of less than 10kg. The total proportion of complications was higher in children with less than 10kg of weight (P<0.001).

CONCLUSION

PD is safe in children with acute renal failure and older children with chronic renal failure; however children with a weight of less than 10kg are more likely to develop complications.

Permanent vascular access survival in children on long-term chronic hemodialysis

The aim of this study is to report a single-center experience regarding the management and outcome of permanent vascular accesses (VA) in children on chronic hemodialysis (HD). We analyzed the survival of permanent VA in 79 pediatric patients with end-stage renal disease patients on chronic HD between January 2000 and December 2008. One hundred and thirty-seven VA [89 native fistulas (AVFs) and 48 grafts (AVGs)] were created in 79 children. The creation of AVFs was significantly more frequent in children weighing >25 kg and AVGs in children weighing <25 kg (p = 0.003). The 1-year primary patency rate was 50% for AVF and 30% for AVG. The secondary patency rates at 1, 2, and 3 years for AVFs were 73, 50, and 20% and for AVGs were 64, 36, and 20%, respectively. The total number of surgical and endovascular interventions was significantly higher in AVGs (p <or=0.05). Access stenosis, thrombosis and infection episodes occurred more frequently in AVG (p = 0.02). VAs had a high rate of interventions. Our study demonstrated better results of AVFs formation over AVGs, for long-term HD access in pediatrics. Surveillance and radiologic procedures are necessary for early detection and treatment of access complications in order to extend access survival.

Optimizing the surgical residents' educational experience on transplant surgery

INTRODUCTION

Surgical specialties with high service demands like transplant surgery are challenged to provide good educational value for rotating surgical residents while maintaining quality patient care. Based on poor resident evaluations, the Resident Review Committee for Surgery (RRC-S) has proposed removing the requirement for transplant surgery rotations from general surgery residency programs.

OBJECTIVES

The objectives of this article are to provide a situation analysis pertaining to the problem of poor resident evaluations from the perspective of the American Society of Transplant Surgeons (ASTS), and to propose an action plan to improve the current situation.

SETTING AND PARTICIPANTS

The Fellowship Training and Curriculum committees of the ASTS together with ASTS leadership and ASTS fellowship program directors collaborated to address these concerns by identifying key contributory factors and by initiating an action plan to correct them.

RESULTS

The following 4 major issues pertaining to transplant surgery rotations were considered most relevant to the problem: (1) high service demands, (2) inadequate prioritization of resident education, (3) competition with fellows for educational opportunities, and (4) the need by many programs to send their residents to other centers to obtain transplant experience. Based on these issues, the ASTS leadership issued directives to all programs with rotating residents to (1) designate a transplant surgeon to resident education experience on transplant; (2) create a service infrastructure that is not dependent on surgical residents; (3) re-educate faculty, fellows, support staff and residents regarding resident expectations on transplant surgery; (4) create a structured and sustainable educational experience; (5) increase resident involvement in surgical procedures; and (6) obtain ongoing feedback from rotating residents and the program directors.

CONCLUSIONS

Transplant surgery can be a valuable educational experience for surgical residents. The ASTS is dedicated to collaborating with general surgery residents and program directors in ongoing efforts to enhance this experience.

Arteriovenous fistula for chronic hemodialysis in pediatric candidates for renal transplantation: Technical details and refinements

AVFs may be considered the best type of venous access for chronic hemodialysis in pediatric patients with more than 20 kg who are not likely to receive a kidney transplant or be transitioned to peritoneal dialysis within one yr. The aim of the study was to report the experience in the creation of AVFs in pediatric candidates for renal transplantation using microsurgical vascular techniques, with emphasis on the details of the surgical technique. Forty children underwent 50 fistula creations - 31 radial-cephalic, 11 brachial-cephalic, five brachial-basilic and three saphenous-femoral. The vein was anastomosed to the artery in an end-to-lateral fashion by using two separate 8/0 prolene running sutures. The overall patency rate was 76.0%:22 (70.9%) of the radial-cephalic fistulas, nine (81.8%) of the brachial-cephalic, five (100.0%) of the brachial-basilic and two (66.6%) of the saphenous-femoral. There was no significant difference in patency rates between the brachial-cephalic, brachial-basilic and radial-cephalic fistulas. The incidences of fistula patency were not different for patients weighing <20 kg compared with patients weighing >20 kg. AVF remains as a satisfactory method for providing hemodialysis in children. The utilization of microsurgical techniques with some technical refinements described herein permits the achievement of high fistula patency rates.

Vascular access complications in long-term pediatric hemodialysis patients

Current data demonstrate pediatric patients who remain on hemodialysis (HD) therapy are more likely to be dialyzed via central venous catheters (CVCs) than arteriovenous grafts (AVGs) and fistulae (AVFs). We retrospectively compared complications and health-related quality of life (HRQOL) associated with different vascular access types at two large centers over a 1-year period. Patients included in the study were younger than 25 years of age, weighed >20 kg, and had received HD for at least 3 months. Thirty CVC patients and 21 AVG/AVF patients received a total of 2,393 and 3,506 HD treatments, respectively. The infectious complication rate was higher for CVC patients, who were hospitalized 3.7 days for each 100 HD treatments versus 0.2 days for AVG/AVF patients (p < 0.01). CVC patients also had a much higher rate of access revision, needing 2.7 hospital days every 100 HD treatments compared with 0.2 days for AVG/AVF patients (p < 0.01). HRQOL scores did not differ between groups. Thus, despite similar HRQOL, CVCs were associated with more complications and greater morbidity when compared with AVG/AVFs. These findings further emphasize the need to use AVG/AVFs as primary HD access for pediatric patients expected to receive a long course of maintenance HD.