Division of Vascular Surgery, University of South Florida, Tampa, Fl; Division of Vascular Surgery, Johns Hopkins Medical Institutions, Baltimore, MD.
Division of Vascular Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; St Vincent's Medical Center, Bridgeport, CT.
J Pediatr Surg. 2020 Jul;55(7):1392-1399. doi: 10.1016/j.jpedsurg.2019.09.017. Epub 2019 Nov 27.
There is paucity of comparative data on the objective performance of arteriovenous fistulas (AVF), grafts (AVG), hemodialysis (HD) catheter and peritoneal dialysis (PD) catheter in the pediatric population.
A retrospective analysis of all patients <21 years in the United States Renal Database System who had an AVF, AVG, HD catheter or PD catheter placed for dialysis access between 1/2007 and 12/2014 was performed. Multivariable cox regression was used to evaluate mortality, patency (primary, primary-assisted and secondary), maturation and catheter survival.
The 11,575 patients studied comprised of 9445 (82%) HD, 1435 (12%) PD, 528 (4.6%) HD to PD and 167 (1.4%) PD to HD patients. The HD subcohort comprised of 1296 (13.7%) AVF initiates, 199 (2.1%) AVG initiates, 1347 (14.3%) AVF converts after initial HD catheter use, 292 (3.1%) AVG converts and 6311 (67%) patients who persistently utilized HD catheters. There was no difference between PD and HD in patients 0-5 (aHR: 1.36; 95% CI: 0.89-2.07; P = 0.15) and 6-12 years (aHR: 1.05; 95% CI: 0.72-1.52; P = 0.8). However, PD was associated with 73% and 76% increase in mortality relative to HD among patients in the 13-17 (aHR: 1.73; 95% CI: 1.35-2.21; P < 0.001) and 18-20 (aHR: 1.76; 95% CI: 1.38-2.24; P < 0.001) age categories. AVG was associated with 78% increase in mortality compared to AVF (aHR: 1.78; 95% CI: 1.41-2.25; P < 0.001). Persistent use of HD catheters was associated with 29% increase in mortality (aHR: 1.29; 95% CI: 1.07-1.57; P = 0.009) compared to initiation and persistent use of AVF. Conversion from HD catheter to AVF was associated with 66% decrease in mortality compared to persistent HD catheter use (aHR: 0.34; 95% CI: 0.28-0.40; P < 0.001). Primary, primary assisted and secondary patency were higher for AVF compared to AVG.
There was no difference in risk adjusted mortality between HD and PD in children less than 13 years. PD is associated with higher mortality compared to HD in adolescents. Initiation of HD with AVF is associated with better patency and patient survival relative to AVG and persistent use of HD catheters in pediatric patients irrespective of transplant potential. Conversion from HD catheter to AVF or AVG in patients who inevitably initiate HD with a catheter is associated with better survival compared to persistent HD catheter use.
Retrospective cohort study.
Level II.
关于动静脉瘘（AVF）、移植物（AVG）、血液透析（HD）导管和腹膜透析（PD）导管在儿科人群中的客观性能的比较数据很少。
对 2007 年 1 月至 2014 年 12 月期间在美国肾脏数据库系统中接受透析通路的所有年龄<21 岁的患者进行了回顾性分析。使用多变量 Cox 回归评估死亡率、通畅率（主要、主要辅助和次要）、成熟度和导管生存率。
研究的 11575 名患者包括 9445 名（82%）HD、1435 名（12%）PD、528 名（4.6%）HD 到 PD 和 167 名（1.4%）PD 到 HD 患者。HD 亚组包括 1296 名（13.7%）AVF 起始患者、199 名（2.1%）AVG 起始患者、1347 名（14.3%）AVF 在初始 HD 导管使用后转换为 AVF 的患者、292 名（3.1%）AVG 转换患者和 6311 名（67%）持续使用 HD 导管的患者。PD 与 HD 在 0-5 岁（aHR：1.36；95%CI：0.89-2.07；P=0.15）和 6-12 岁（aHR：1.05；95%CI：0.72-1.52；P=0.8）患者中无差异。然而，在 13-17 岁（aHR：1.73；95%CI：1.35-2.21；P<0.001）和 18-20 岁（aHR：1.76；95%CI：1.38-2.24；P<0.001）年龄组中，PD 与 HD 相比，死亡率增加了 73%和 76%。与 AVF 相比，AVG 与死亡率增加 78%相关（aHR：1.78；95%CI：1.41-2.25；P<0.001）。与起始和持续使用 AVF 相比，持续使用 HD 导管与死亡率增加 29%相关（aHR：1.29；95%CI：1.07-1.57；P=0.009）。与持续使用 HD 导管相比，从 HD 导管转换为 AVF 与死亡率降低 66%相关（aHR：0.34；95%CI：0.28-0.40；P<0.001）。与 AVG 相比，AVF 的主要、主要辅助和次要通畅率更高。
在小于 13 岁的儿童中，HD 和 PD 的风险调整死亡率无差异。与 HD 相比，PD 在青少年中与更高的死亡率相关。与 AVG 和持续使用 HD 导管相比，起始时使用 AVF 进行 HD 与更好的通畅率和患者生存率相关，无论移植潜力如何。在不可避免地开始使用 HD 导管的患者中，从 HD 导管转换为 AVF 或 AVG 与持续使用 HD 导管相比，生存率更高。
回顾性队列研究。
二级。
