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.