Baracco Rossana, Mattoo Tej, Jain Amrish, Kapur Gaurav, Valentini Rudolph P
Department of Pediatrics, Division of Pediatric Nephrology, Children's Hospital of Michigan/Wayne State University, 3901 Beaubien St, Detroit, MI, 48201, USA.
Pediatr Nephrol. 2014 Oct;29(10):2013-20. doi: 10.1007/s00467-013-2744-9. Epub 2014 Jan 29.
An internal permanent vascular access [arteriovenous fistula (AVF) or arteriovenous graft (AVG)] is preferred over central venous catheters (CVC) for chronic hemodialysis. However, CVC remain the most commonly used access in children. The objective of this study was to evaluate our experience with AVF.
We conducted a retrospective chart review of children aged 1-18 years on chronic hemodialysis from 2001 to 2012. Patients were divided into three time periods: 2001-2005, 2006-2009 and 2010-2012. A systematic approach to AVF placement was introduced in our department in 2006 which resulted in a greater number of AVF being placed and used, but the access failure rate was still higher than desired. In 2010, a more experienced vascular surgeon was contacted to perform AVF surgery in our most difficult AVF candidates.
Sixty-five AVF were created in 55 patients (67.3 % male). The median age of the patients was 14 (3-18) years. Forty-one (63.1 %) AVF were used successfully, and this number increased from 52.6 to 57.6 to 92.3 % over the three time periods, respectively. Over time, AVF use rates increased and CVC use decreased. By 2012 only 7.7 % of our patients were using a CVC. The primary patency rate was 42.9 % at 1 year; secondary patency rates were 100 and 93.8 % at 1 and 2 years, respectively. Infection and hospitalization rates were higher for CVC than for AVF [0.8 vs. 0.1 infections per access-year (p < 0.001) and 0.9 vs. 0.2 hospitalizations per access-year (p < 0.001)].
With a dedicated approach and vascular access team it is possible to decrease CVC and increase AVF use in children on hemodialysis. In our study, increased AVF use resulted in decreased access-related infection and hospitalization rates.
对于慢性血液透析，永久性体内血管通路[动静脉内瘘（AVF）或动静脉移植物（AVG）]优于中心静脉导管（CVC）。然而，CVC仍是儿童中最常用的血管通路。本研究的目的是评估我们在AVF方面的经验。
我们对2001年至2012年期间1至18岁接受慢性血液透析的儿童进行了回顾性病历审查。患者分为三个时间段：2001 - 2005年、2006 - 2009年和2010 - 2012年。2006年我们科室引入了一种系统的AVF置入方法，这使得更多的AVF得以置入和使用，但血管通路失败率仍高于预期。2010年，我们联系了一位经验更丰富的血管外科医生为最难建立AVF的患者进行手术。
55例患者（67.3%为男性）共建立了65个AVF。患者的中位年龄为14（3 - 18）岁。41个（63.1%）AVF成功使用，这一数字在三个时间段分别从52.6%增至57.6%再到92.3%。随着时间推移，AVF使用率上升而CVC使用率下降。到2012年，我们只有7.7%的患者使用CVC。1年时的初次通畅率为42.9%；1年和2年时的二次通畅率分别为100%和93.8%。CVC的感染率和住院率高于AVF[每血管通路年感染率分别为0.8和0.1（p < 0.001），每血管通路年住院率分别为0.9和0.2（p < 0.001）]。
通过采用专门的方法和血管通路团队，有可能减少血液透析儿童患者的CVC使用并增加AVF使用。在我们的研究中，增加AVF使用导致与血管通路相关的感染率和住院率下降。
