Vascular access in children requiring maintenance haemodialysis: a consensus document by the European Society for Paediatric Nephrology Dialysis Working Group

Abstract

Background There are three principle forms of vascular access available for the treatment of children with end stage kidney disease (ESKD) by haemodialysis: tunnelled catheters placed in a central vein (central venous lines, CVLs), arteriovenous fistulas (AVF), and arteriovenous grafts (AVG) using prosthetic or biological material. Compared with the adult literature, there are few studies in children to provide evidence based guidelines for optimal vascular access type or its management and outcomes in children with ESKD. Methods The European Society for Paediatric Nephrology Dialysis Working Group (ESPN Dialysis WG) have developed recommendations for the choice of access type, pre-operative evaluation, monitoring, and prevention and management of complications of different access types in children with ESKD. Results For adults with ESKD on haemodialysis, the principle of “Fistula First” has been key to changing the attitude to vascular access for haemodialysis. However, data from multiple observational studies and the International Paediatric Haemodialysis Network registry suggest that CVLs are associated with a significantly higher rate of infections and access dysfunction, and need for access replacement. Despite this, AVFs are used in only ∼25% of children on haemodialysis. It is important to provide the right access for the right patient at the right time in their life-course of renal replacement therapy, with an emphasis on venous preservation at all times. While AVFs may not be suitable in the very young or those with an anticipated short dialysis course before transplantation, many paediatric studies have shown that AVFs are superior to CVLs. Conclusions Here we present clinical practice recommendations for AVFs and CVLs in children with ESKD. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system has been used to develop and GRADE the recommendations. In the absence of high quality evidence, the opinion of experts from the ESPN Dialysis WG is provided, but is clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to local expertise and individual patient needs as appropriate.

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

“…In a small study of pediatric hemodialysis patients with CVC, alteplase was found to be significantly more effective than heparin in preventing catheter clot formation 22 . Given these results, the European Society for Pediatric Nephrology Dialysis Working Group (ESPNDWG) recommends using tPA as a catheter locking solution to prevent thrombosis 23 . Additionally, fibrin sheath formation may occur in up to 50% of patients with CVC 6 .…”

“…Without these signs, routine imaging is not recommended. As for thrombus prevention, ESPNDWG recommends using anti‐platelet agents like aspirin, clopidogrel, and ticlopidine within the first few months of AVF creation 34–36 …”

Silent and dangerous: catheter-associated right atrial thrombus (CRAT) in children on chronic haemodialysis

“…Haemodialysis (HD) via a central venous catheter (CVC) for children with kidney failure with replacement therapy (KFRT) remains the commonest form of dialysis in childhood [1]. For young children aged < 2 years, peritoneal dialysis (PD) remains the recommended dialysis access of choice [2], as this modality is associated with fewer complications [1]. If the duration of dialysis is estimated to be 'short-term', for example less than 6 months before a planned kidney transplant, dialysis via a CVC may be adequate to access the vascular system.…”

“…However, for longer term HD, consideration should be given to form an arteriovenous fistula (AVF), as long-term HD via a CVC carries significant risks including infection, malfunction, inadequate dialysis, hospitalisation, and central venous stenosis [4]. Despite the known lower complication rates associated with AVF versus CVC [1], European and US databases highlight that the vast majority of children on chronic HD continue to receive dialysis via a CVC [5,6]. Reasons for this may include lack of surgical expertise, clinician preference, and patient and family acceptance of an AVF.…”

Vascular Access for Hemodialysis in Pediatric Age

“…There are three principle forms of vascular access available for the treatment of children with end stage kidney disease (ESKD) by haemodialysis: tunnelled catheters placed in a central vein (central venous lines, CVLs), arteriovenous fistulas (AVF), and arteriovenous grafts (AVG) using prosthetic or biological material. Compared with the adult literature, there are few studies in children to provide evidence based guidelines for optimal vascular access type or its management and outcomes in children with ESKD (Shroff et al, 2019).…”