Complications of vascular access in children with chronic end-stage renal disease

Abstract

Introduction. Obtaining vascular access that allows long-term hemodialysis of children with stage 5D chronic kidney disease is a priority in the management of these patients. Complications of central venous catheters and arteriovenous fistula are directly correlated with the morbidity and quality of life of these children. The objective of the study was to assess complications of vascular access in children on long-term hemodialysis by arteriovenous fistula or central venous line. Methods. We followed 40 patients in the hemodialysis program for a period of 18 months; in 22, vascular access was by arteriovenous fistula, and 18 were dialyzed on a central venous line. Results. All 22 patients were accepted for AVF at a vein diameter of at least 3 mm, and this probably contributed to the high rate of primary maturation (86%). In the majority of these patients (64%) was brachiocephalic fistula versus radiocephalic (18%), in most cases the decision being supported by small diameters of radial artery and distal cephalic vein. Three of the arteriovenous fistulas performed had a primary failure, and one a secondary failure; 2 of the patients with arteriovenous fistula failure had to be subsequently dialyzed by central venous line and one by peritoneal dialysis, while the fourth benefited from a new arteriovenous fistula. Six patients developed fistula aneurysms, one of them evolving into a pseudoaneurysm with spontaneous rupture and hemorrhagic shock and requiring emergency ligation. Two patients developed significant vein stenosis in the proximity of the anastomosis. All 6 patients with aneurysmal fistula had hypertension, and 3 of them had thrombotic venous stenoses/occlusion in the main deep veins upstream of the fistula in the context of prolonged use of central venous lines in the jugular veins and subclavian veins. The average age of the children was 13.35 years (range 9-18 years) and the average weight was 38.6 kg (range 23-58 kg). Of the patients on dialysis on central venous lines, 76% (16 patients) had at least one episode of sepsis that required hospitalization, and all patients who were dialyzed on the catheter (from the beginning or after fistula failure) experienced at least one episode of vein thrombosis that required catheter change. In 8 (38%) of the 21 patients using central venous lines, thrombotic occlusion/stenosis of at least one persistent deep vein was observed at 3 months after the removal of the central venous line from the venous axis. Conclusions. Complications of venous access in children with hemodialysis are very common and have a major impact on the morbidity and quality of life of these patients. In this context, a multidisciplinary team (pediatric nephrologist, specialist in vascular imaging, and vascular surgeon) is needed to follow these patients in order to prevent and treat these complications.

Keywords

• arteriovenous fistula
• vascular access
• hemodialysis
• chronic kidney disease
• children