Title: Titel van de Slide
1Hemodialysis access guidelines, evidence and
controversies
Marc R Lilien, MD, PhD Pediatric nephrologist
2Current guidelines on vascular access
- - European Best Practice Guidelines on Vascular
AccessNephrol.Dial.Transplant. 2007 (22) Suppl
2 ii88-ii117 - - NKF K/DOQI guidelines Clinical Practice
Guidelines and Clinical Practice Recommendations,
2006 updates Vascular AccessClinical Practice
Recommendation 8 Vascular Access in Pediatric
Patientshttp//www.kidney.org/professionals/kdoqi
/guideline_upHD_PD_VA/va_rec8.htm
38.1 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 gt 20
kg, who are expected to wait gt 1 year for a
kidney transplant
48.1.1 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
58.1.1 Permanent access in the form of a fistula
or graft?
68.1.1 Permanent access in the form of a fistula
or graft?
78.1.1 Permanent access in the form of a fistula
or graft?
88.1.1 Permanent access in the form of a fistula
or graft?
98.1.1 Permanent access in the form of a fistula
or graft
108.1.1 Permanent access in the form of a fistula
or graft
118.1.1 Permanent access in the form of a fistula
or graft
128.1.1 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 gt 60
months - Maturation appears better with microsurgical
technique
138.1.2 Circumstances in which a CVC may be
acceptable patient size ?
Long-term patency R-C AVF in children lt 10 kg
half-life 24 months
148.2 Stenosis surveillance
- - An AVG stenosis surveillance protocol should be
established to detect venous anastomosis stenosis
and direct patients for surgical revision or PTA.
158.2 Stenosis surveillance how?
Phase I no monitoring
Phase II dynamic venous pressure monitoring
Phase III access blood flow monitoring
168.2 Stenosis surveillance how?
2 needle access is mandatory for flow monitoring
178.2 Stenosis surveillance how ?
188.2 Stenosis surveillance how?
198.3 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.
208.3.3 Catheter size
http//www.kidney.org/professionals/kdoqi/guidelin
e_upHD_PD_VA/va_rec8.htm
218.3.3 Catheter size
Insertion of catheters gt 6 Fr in children lt 10 kg
is associated with a significantly higher risk of
complications
228.3.2 Anatomic site
238.3.2 Anatomic site
248.3.2 Anatomic site
Subclavian 74Int. jugular 8
25Conclusions
- - 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