Titel van de Slide

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Hemodialysis access guidelines, evidence and
controversies
Marc R Lilien, MD, PhD Pediatric nephrologist
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Current 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

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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 gt 20
  kg, who are expected to wait gt 1 year for a
  kidney transplant

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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

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8.1.1 Permanent access in the form of a fistula
or graft?
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8.1.1 Permanent access in the form of a fistula
or graft?
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8.1.1 Permanent access in the form of a fistula
or graft?
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8.1.1 Permanent access in the form of a fistula
or graft?
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8.1.1 Permanent access in the form of a fistula
or graft
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8.1.1 Permanent access in the form of a fistula
or graft
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8.1.1 Permanent access in the form of a fistula
or graft
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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 gt 60
  months
• Maturation appears better with microsurgical
  technique

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8.1.2 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
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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.

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8.2 Stenosis surveillance how?
Phase I no monitoring
Phase II dynamic venous pressure monitoring
Phase III access blood flow monitoring
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8.2 Stenosis surveillance how?
2 needle access is mandatory for flow monitoring
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8.2 Stenosis surveillance how ?
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8.2 Stenosis surveillance how?
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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.

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8.3.3 Catheter size
http//www.kidney.org/professionals/kdoqi/guidelin
e_upHD_PD_VA/va_rec8.htm
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8.3.3 Catheter size
Insertion of catheters gt 6 Fr in children lt 10 kg
is associated with a significantly higher risk of
complications
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8.3.2 Anatomic site
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8.3.2 Anatomic site
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8.3.2 Anatomic site
Subclavian 74Int. jugular 8
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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