HEMODIALYSIS ACCESS IN THE PEDIATRIC-PATIENT POPULATION

BACKGROUND: Each year, three to five children per million develop chro nic renal failure. Of these, 70% will require dialysis for short perio ds, and 23% will require prolonged hemodialysis support. It is in the latter group that difficulty is encountered in establishing dialysis a ccess. METHODS: From 1985 to 1992, we provided hemodialysis access for a group of 24 children. there were 16 boys and 8 girls, with a mean a ge of 11.1 +/- 4 years (range 3 to 17). All children were significantl y below the 50th percentile weight for their age and sex. Seven childr en entered hemodialysis following failed peritoneal dialysis after an average of 21 +/- 10.5 months. Seventeen patients received a renal tra nsplant. Seven of these children have resumed hemodialysis. RESULTS: T he technique for establishing hemodialysis was varied: 15 arteriovenou s fistulae, 37 expanded polytetrafluoroethylene (ePTFE) bridge grafts, 9 bovine arteriovenous bridge grafts, and 29 chronic central venous c atheters. The overall mean functional patency of the fistulae was 6.2 +/- 10.2 months. One third of these fistulae failed to mature sufficie ntly to permit their use for dialysis purposes. Twenty-one upper extre mity ePTFE grafts were implanted, with a mean functional patency of 11 +/- 11.1 months. Sixteen groin loop grafts were utilized, with a prim ary patency of only 4.1 +/- 5 months. Thrombectomy was performed in 25 cases (patch or interposition in 8 cases), with a secondary patency i n these grafts of 10.5 +/- 17 months. an inability to achieve access i n 2 children resulted in the creation of unusual types of access: an a orto-caval fistula and an axillo-femoral fistula and a combination of single-needle puncture of an immature fistula with one lumen of a Perm Cath. There were eight ePTFE graft infections, with graft loss occurri ng in seven cases. Superior vena caval occlusion occurred in two patie nts, inferior vena caval thrombosis in one patient, and axillo-subclav ian venous occlusion in two patients. Development of central venous oc clusions significantly increased the difficulty in establishing dialys is access. The total dialysis period provided by the 90 primary proced ures performed in this study was 658 months. Each procedure, therefore , provided access for a mean duration of only 7.3 months. CONCLUSION: Providing dialysis access in the pediatric population is a time-consum ing and frustrating challenge. We believe that all patients with renal dysfunction should have their conditions managed as potential long-te rm dialysis candidates. Therefore, our philosophy is to achieve maxima l use from each access site. Although the primary patency of upper-arm ePTFE grafts was greater than that for the forearm fistulae in this s tudy, failure of the upper-arm graft can result in loss of the limb fo r the purposes of future dialysis access. consequently, we strongly ad vocate the ''distal before proximal'' and ''autogenous before prosthet ic'' dogma in providing pediatric hemodialysis access.