Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland.
Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
Am J Kidney Dis. 2019 Aug;74(2):193-202. doi: 10.1053/j.ajkd.2019.02.014. Epub 2019 Apr 19.
RATIONALE & OBJECTIVE: Arteriovenous fistulas (AVFs) have been recommended as the preferred vascular access for pediatric patients on maintenance hemodialysis (HD), but data comparing AVFs with other access types are scant. We studied vascular access choice, placement, complications, and outcomes in children.
Prospective observational cohort study.
SETTING & PARTICIPANTS: 552 children and adolescents from 27 countries on maintenance HD followed up prospectively by the International Pediatric HD Network (IPHN) Registry between 2012 and 2017.
Type of vascular access: AVF, central venous catheter (CVC), or arteriovenous graft.
Infectious and noninfectious vascular access complication rates, dialysis performance, biochemical and hematologic parameters, and clinical outcomes.
Univariate and multivariable linear mixed models, generalized linear mixed models, and proportional hazards models; cumulative incidence functions.
During 314 cumulative patient-years, 628 CVCs, 225 AVFs, and 17 arteriovenous grafts were placed. One-third of the children with an AVF required a temporary CVC until fistula maturation. Vascular access choice was associated with age and expectations for early transplantation. There was a 3-fold higher living related transplantation rate and lower median time to transplantation of 14 (IQR, 6-23) versus 20 (IQR, 14-36) months with CVCs compared with AVFs. Higher blood flow rates and Kt/V were achieved with AVFs than with CVCs. Infectious complications were reported only with CVCs (1.3/1,000 catheter-days) and required vascular access replacement in 47%. CVC dysfunction rates were 2.5/1,000 catheter-days compared to 1.2/1,000 fistula-days. CVCs required 82% more revisions and almost 3-fold more vascular access replacements to a different site than AVFs (P<0.001).
Clinical rather than population-based data.
CVCs are the predominant vascular access choice in children receiving HD within the IPHN. Age-related anatomical limitations and expected early living related transplantation were associated with CVC use. CVCs were associated with poorer dialysis efficacy, higher complication rates, and more frequent need for vascular access replacement. Such findings call for a re-evaluation of pediatric CVC use and practices.
动静脉瘘（AVF）被推荐为接受维持性血液透析（HD）的儿科患者的首选血管通路，但比较 AVF 与其他通路类型的数据很少。我们研究了儿童的血管通路选择、置管、并发症和结局。
前瞻性观察队列研究。
2012 年至 2017 年，国际儿科 HD 网络（IPHN）注册中心前瞻性随访了来自 27 个国家的 552 名接受维持性 HD 的儿童和青少年患者。
血管通路类型：AVF、中央静脉导管（CVC）或动静脉移植物。
感染性和非感染性血管通路并发症发生率、透析效果、生化和血液学参数以及临床结局。
单变量和多变量线性混合模型、广义线性混合模型和比例风险模型；累积发生率函数。
在 314 个累积患者年中，共置管 628 根 CVC、225 根 AVF 和 17 根动静脉移植物。三分之一的 AVF 患儿需要临时 CVC 等待瘘管成熟。血管通路的选择与年龄和对早期移植的期望有关。与 AVF 相比，CVC 组的活体亲属移植率高 3 倍，中位时间为 14（IQR，6-23）个月，而 AVF 组为 20（IQR，14-36）个月。与 CVC 相比，AVF 组的血流量和 Kt/V 更高。仅报告了与 CVC 相关的感染性并发症（1.3/1000 导管日），需要更换血管通路的比例为 47%。CVC 功能障碍的发生率为 2.5/1000 导管日，而 AVF 为 1.2/1000 瘘管日。CVC 需要进行 82%的更多修订，并且几乎是 AVF 的 3 倍，需要更换到不同部位（P<0.001）。
临床而非基于人群的数据。
在 IPHN 接受 HD 的儿童中，CVC 是主要的血管通路选择。与年龄相关的解剖学限制和预期的早期活体亲属移植与 CVC 的使用有关。CVC 与较差的透析效果、更高的并发症发生率和更频繁的血管通路更换相关。这些发现呼吁重新评估儿科 CVC 的使用和实践。
