Update on the creation and maintenance of arteriovenous fistulas for haemodialysis in children
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EDUCATIONAL REVIEW
Update on the creation and maintenance of arteriovenous fistulas for haemodialysis in children Evgenia Preka 1
&
Rukshana Shroff 2 & Lynsey Stronach 2 & Francis Calder 2,3 & Constantinos J. Stefanidis 4
Received: 29 March 2020 / Revised: 2 August 2020 / Accepted: 26 August 2020 # IPNA 2020
Abstract Arteriovenous fistulas (AVFs) are widely used for haemodialysis (HD) in adults with stage 5 chronic kidney disease (CKD 5) and are generally considered the best form of vascular access (VA). The ‘Fistula First’ initiative in 2003 helped to change the culture of VA in adults. However, this cultural change has not yet been adopted in children despite the fact that a functioning AVF is associated with lower complication rates and longer access survival than a central venous line (CVL). For children with CKD 5, especially when kidney failure starts early in life, there is a risk that all VA options will be exhausted. Therefore, it is essential to develop long-term strategies for optimal VA creation and maintenance. Whilst AVFs are the preferred VA in the paediatric population on chronic HD, they may not be suitable for every child. Recent guidelines and observational data in the paediatric CKD 5 population recommend switching from a ‘Catheter First’ to ‘Catheter Last’ approach. In this review, recent evidence is summarized in order to promote change in current practices. Keywords Arteriovenous fistula . Vascular access . Paediatric haemodialysis . Children
Introduction One of the most challenging aspects of kidney replacement therapy (KRT) in children is the creation and maintenance of a functioning vascular access (VA) to provide adequate blood flow for uremic solute removal during haemodialysis (HD), whilst minimizing the risk of systemic infections and preserving VA choices for future dialysis. There are three common forms of VA: tunnelled cuffed lines placed in a central vein (CVL), arteriovenous fistulas (AVF) and arteriovenous grafts (AVG) using prosthetic or biological material. AVFs are the preferred VA for children on HD. Compared with a CVL, a
* Evgenia Preka [email protected] 1
Southampton Children’s Hospital and University of Southampton School of Medicine, Tremona Road, Southampton SO16 6YD, UK
2
UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
3
Evelina London Children’s Hospital NHS Foundation Trust, London, UK
4
“Mitera” Children’s Hospital, Maroussi, Athens, Greece
functional AVF is associated with better dialysis adequacy, significantly lowering complication rates and access failure. However, CVLs remain the most frequently used VA in all paediatric age groups, despite international recommendations [1–4]. This is likely due to the widespread familiarity and perceived ‘convenience’ of CVLs for dialysis. To increase the use of AVFs it is important that standards for the creation and maintenance of AVF in children are observed as the paediatric community work towards a ‘Fistula First, Catheter Last’ culture (Fig. 1). One of the difficul
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