1. Hemodialysis access: guidelines, evidence and controversies Marc R Lilien, MD, PhD Pediatric nephrologist

2. Current guidelines on vascular access -European Best Practice Guidelines on Vascular Access Nephrol.Dial.Transplant. 2007; (22) [Suppl 2]: ii88-ii117 -NKF K/DOQI guidelines: Clinical Practice Guidelines and Clinical Practice Recommendations, 2006 updates: Vascular Access Clinical Practice Recommendation 8: Vascular Access in Pediatric Patients http://www.kidney.org/professionals/kdoqi/guideline_upHD_PD_VA/va_rec8.htm

3. 8.1 Choice of access type -8.1.1 Permanent access in the form of a fistula or graft is the preferred form of vascular access for most pediatric patients on maintenance HD therapy -8.1.2 Circumstances in which a CVC may be acceptable -Lack of local surgical expertise -Patient size too small -Temporary access (bridging to PD, expeditious Tx) -8.1.3 Lack of surgical expertise in the pediatric setting -8.1.4 Permanent vascular access in children > 20 kg, who are expected to wait > 1 year for a kidney transplant

4. 8.1.1 Permanent access in the form of a fistula or graft: preservation is the key -Early education of CRF patients -Preferential venipuncture from and i.v. lines in the dorsal hand veins -preoperative Duplex ultrasound examination of upper extremity arteries and veins -Central vein evaluation in appropriate patients known to have a previous catheter

5. 8.1.1 Permanent access in the form of a fistula or graft?

9. 8.1.1 Permanent access in the form of a fistula or graft

12. 8.1.1 Permanent access in the form of a fistula or graft? -CVC survival is poor: 1 year secondary patency rate 30%-60% -CVC insertion is associated with central venous stenosis, jeopardizing future creation of AVF -AVF and AVG half life in pediatric patients > 60 months -Maturation appears better with microsurgical technique

13. 8.1.2 Circumstances in which a CVC may be acceptable: patient size ? Long-term patency R-C AVF in children < 10 kg: half-life 24 months

14. 8.2 Stenosis surveillance -An AVG stenosis surveillance protocol should be established to detect venous anastomosis stenosis and direct patients for surgical revision or PTA.

15. 8.2 Stenosis surveillance: how? Phase I: no monitoring Phase II: dynamic venous pressure monitoring Phase III: access blood flow monitoring

16. 8.2 Stenosis surveillance: how? 2 needle access is mandatory for flow monitoring

17. 8.2 Stenosis surveillance: how ?

19. 8.3 Catheter sizes, anatomic sites and configurations -8.3.1 Catheter size should be matched to patient size with the goal of minimizing intraluminal trauma and obstruction of blood flow while allowing sufficient blood flow for adequate HD. -8.3.2 External cuffed access should be placed in the internal jugular with the distal tip placed in the right atrium. -8.3.3 The BFR of an external access should be minimally 3 to 5 ml/kg/min and should be adequate to deliver the prescribed HD dose.

20. 8.3.3 Catheter size http://www.kidney.org/professionals/kdoqi/guideline_upHD_PD_VA/va_rec8.htm

21. 8.3.3 Catheter size Insertion of catheters > 6 Fr in children < 10 kg is associated with a significantly higher risk of complications

22. 8.3.2 Anatomic site

24. Subclavian 74% Int. jugular 8%

25. Conclusions -Preserve upper extremity peripheral and central veins for future access -Create permanent access in advance -Establish a dedicated microsurgical approach -Monitor access function, preferably by BFR monitoring -When CVC is unavoidable, avoid a subclavian approach