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Nephrology
Figure 3: Pre-operative Vascular Imaging Using Ultrasound
decrease the vasospasm, allowing for a finer anastomosis. The use of
Mapping of Artery (Left) and Vein (Right)
a low-dose dihydropyridine calcium channel blocker with vasodilatory
properties, such as amlodipine, may allow for improved patency.
The International Pediatric Fistula First Initiative –
A Work in Progress
The IPPFI was established in 2005 to help paediatric nephrologists and
dialysis staff members recognise the advantages of AVF placement in
children. This educational and research initiative was championed by a
team of two paediatric nephrologists, with significant contributions
from vascular access surgeons (VAS) and an interventional radiologist
Figure 4: Venography in a Child as Part of Pre-operative
(IR). Following the successful attainment of local institutional review
Evaluation for Arteriovenous Fistula Typically Performed in board approval, site visits were conducted by co-chair members of the
Those with a Prior Central Venous Catheter
IPFFI. A survey tool directed at dialysis staff, nephrologists, VAS and IR
was utilised. An educational DVD with components directed at
nephrologists, VAS and IR was shown, and a post-intervention survey
was conducted. Additional educational tools included patient hand-
outs and pamphlets. More recently, a workshop for dialysis staff
members, nephrologists, IR and VAS took place. It is the hope of the
investigators that further promotion of AVF in children will result in
improved placement rates and dialysis outcomes. Currently, this
initiative has been made available to participating members of the
Midwest Pediatric Nephrology Consortium, but plans to extend the
programme outside this region are forthcoming.
Summary
Challenges Unique to the Paediatric Patient Many challenges exist in the paediatric ESRD patient. HD is the most
It is often said that children are not mini-adults and this is quite true in frequently used modality for RRT in children. Optimal HD in children,
paediatric HD vascular access. Many providers have a misconception such as that in adults, hinges greatly on a functional and reliable
that children do not want to ‘get stuck’ with large cannulation vascular access. AVFs should be considered in the paediatric ESRD
needles.
2
However, in one paediatric study of patients initially dialysed patient, even in small children. Pre-operative planning with vascular
using a CVC and later changed to an AVF, 70 of 75 children (93%) imaging and early referral to surgery for AVF placement should occur
stated they would not resume CVC use.
13
Alternatively, AVF or AVG at CKD stage 4 to allow sufficient maturation time for AVF with
placement may not be possible in a select group of patients, particularly avoidance of need for CVC. Intra-operative adjuncts such as loupes or
those with contractures in whom accessing an AVF/AVG may be nearly an operative microscope in the hands of an experienced surgeon can
impossible. Children with developmental delay may be candidates for also be helpful in overcoming anatomical barriers to AVF in children.
AVF/AVG placement, but based on their developmental abilities may
lack the capacity to comprehend the cannulation process. In these While renal transplantation and PD are often preferred forms of RRT
cases, a psychology, child life or recreational therapy consult may be in children, these therapies are either unavailable or unfeasible for
beneficial for behaviour modification to overcome this potential barrier. some children. Therefore, it is imperative that nephrologists and
dialysis staff continue to strive to improve HD outcomes in children.
An additional consideration in the paediatric patient is that due to Programmes such as IPFFI should help paediatric care providers in
increased vascular reactivity, children may have a local vasospasm that conquering barriers to AVF placement in children, thereby lowering
may pre-empt thrombosis or stenosis. In these patients, our morbidity and improving long-term outcomes in this vulnerable
unpublished data have shown that intra-operative papaverine can patient population. ■
1. U.S. Renal Data System, USRDS 2007 Annual Report Annual at: www.spitfire.emmes.com/study/ped/annlrept.html. gaining paediatric vascular access for haemodialysis,
Report: Atlas of Chronic Kidney Disease and End-Stage Renal 5. Robbin ML, Gallichio MH, Deierhoi MH, et al., US vascular Microsurgery, 1993; 14:276–9.
Disease in the United States, Bethesda, Maryland: National mapping before hemodialysis access placement, Radiology, 10. Bagolan P, Spagnoli A, Ciprandi G, et al., A ten-year
Institutes of Health, National Institute of Diabetes and 2000; 217:83–8. experience of Brescia-Cimino arteriovenous fistula in children:
Digestive and Kidney Diseases, 2007. 6. Gooding GA, Hightower DR, Moore EH, et al., Obstruction of technical evolution and refinements, J Vasc Surg,
2. U.S. Renal Data System, USRDS 2008 Annual Data Report: Atlas the superior vena cava or subclavian veins: sonographic 1998;27:640–44.
of Chronic Kidney Disease and End-Stage Renal Disease in the diagnosis, Radiology, 1986;159:663–5. 11. Chand DH, Valentini RP, International pediatric fistula first
United States, Bethesda, Maryland: National Institutes of 7. Sheth RD, Brandt ML, Brewer ED, et al., Permanent initiative: a call to action, Am J Kidney Dis, 2008;51:
Health, National Institute of Diabetes and Digestive and hemodialysis vascular access survival in children and 1016–24.
Kidney Diseases, 2008. adolescents with end-stage renal disease, Kidney Int, 12. Gradman WS, Lerner G, Mentser M, et al., Experience with
3. NKF-DOQI clinical practice guidelines for vascular access, 2002;62:1864–9. autogenous arteriovenous access for hemodialysis in children
National Kidney Foundation-Dialysis Outcomes Quality 8. Bourquelot P, Cussenot O, Corbi P, et al., Microsurgical and adolescents, Ann Vasc Surg, 2005;19:609–12.
Initiative, Am J Kidney Dis, 1997;30:S150–91. creation and follow-up of arteriovenous fistulae for chronic 13. Brittinger WD, Walker G, Twittenhoff WD, Konrad N,
4. North American Pediatric Renal Trials and Collaborative Studies haemodialysis in children, Pediatr Nephrol, 1990;4:156–9. Vascular access for hemodialysis in children, Pediatr Nephrol,
(NAPRTCS) 2007 Annual Report, Dialysis Access Data. Available 9. Sanabia J, Polo JR, Morales MD, et al., Microsurgery in 1997;11: 87–95.
28 EUROPEAN PAEDIATRICS
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