hemodialysis access: guidelines, evidence and controversies
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Hemodialysis access: guidelines, evidence and controversies
Marc R Lilien, MD, PhD
Pediatric nephrologist
Current guidelines on vascular access
- European Best Practice Guidelines on Vascular Access
Nephrol.Dial.Transplant. 2007; (22) [Suppl 2]: ii88-ii117
- NKF K/DOQI guidelines: Clinical Practice Guidelines and Clinical
Practice Recommendations, 2006 updates: Vascular Access
Clinical Practice Recommendation 8: Vascular Access in Pediatric
Patients
http://www.kidney.org/professionals/kdoqi/guideline_upHD_PD_VA/va_rec8.htm
8.1 Choice of access type
- 8.1.1 Permanent access in the form of a fistula or graft is the
preferred form of vascular access for most pediatric patients on
maintenance HD therapy
- 8.1.2 Circumstances in which a CVC may be acceptable
- Lack of local surgical expertise
- Patient size too small
- Temporary access (bridging to PD, expeditious Tx)
- 8.1.3 Lack of surgical expertise in the pediatric setting
- 8.1.4 Permanent vascular access in children > 20 kg, who are
expected to wait > 1 year for a kidney transplant
8.1.1 Permanent access in the form of a fistula or graft: preservation is the key
- Early education of CRF patients
- Preferential venipuncture from and i.v. lines in the dorsal hand
veins
- preoperative Duplex ultrasound examination of upper extremity
arteries and veins
- Central vein evaluation in appropriate patients known to have a
previous catheter
8.1.1 Permanent access in the form of a fistula or graft?
8.1.1 Permanent access in the form of a fistula or graft?
8.1.1 Permanent access in the form of a fistula or graft?
8.1.1 Permanent access in the form of a fistula or graft?
8.1.1 Permanent access in the form of a fistula or graft
8.1.1 Permanent access in the form of a fistula or graft
8.1.1 Permanent access in the form of a fistula or graft
8.1.1 Permanent access in the form of a fistula or graft?
- CVC survival is poor: 1 year secondary patency rate 30%-60%
- CVC insertion is associated with central venous stenosis,
jeopardizing future creation of AVF
- AVF and AVG half life in pediatric patients > 60 months
- Maturation appears better with microsurgical technique
8.1.2 Circumstances in which a CVC may be acceptable: patient size ?
Long-term patency R-C AVF in children < 10 kg: half-life 24 months
8.2 Stenosis surveillance
- An AVG stenosis surveillance protocol should be established to
detect venous anastomosis stenosis and direct patients for surgical
revision or PTA.
8.2 Stenosis surveillance: how?
Phase I: no monitoring
Phase II: dynamic venous pressure monitoring
Phase III: access blood flow monitoring
8.2 Stenosis surveillance: how?
2 needle access is mandatory for flow monitoring
8.2 Stenosis surveillance: how ?
8.2 Stenosis surveillance: how?
8.3 Catheter sizes, anatomic sites and configurations
- 8.3.1 Catheter size should be matched to patient size with the goal
of minimizing intraluminal trauma and obstruction of blood flow
while allowing sufficient blood flow for adequate HD.
- 8.3.2 External cuffed access should be placed in the internal jugular
with the distal tip placed in the right atrium.
- 8.3.3 The BFR of an external access should be minimally 3 to 5
ml/kg/min and should be adequate to deliver the prescribed HD
dose.
8.3.3 Catheter size
http://www.kidney.org/professionals/kdoqi/guideline_upHD_PD_VA/va_rec8.htm
8.3.3 Catheter size
Insertion of catheters > 6 Fr in children < 10 kg is associated with a significantly higher risk of complications
8.3.2 Anatomic site
8.3.2 Anatomic site
8.3.2 Anatomic site
Subclavian 74%Int. jugular 8%
Conclusions
- Preserve upper extremity peripheral and central veins for future
access
- Create permanent access in advance
- Establish a dedicated microsurgical approach
- Monitor access function, preferably by BFR monitoring
- When CVC is unavoidable, avoid a subclavian approach