Abstract
Background
The vascular access (VA) is the life-line for children with kidney failure (KT) on hemodialysis (HD). The European Society for Paediatric Nephrology Dialysis Working Group suggested that children requiring HD start with a functioning arteriovenous fistula (AVF) but a tunnelled catheter (TC) can be placed instead where a short period on HD is anticipated before kidney transplantation (KT) (NDT 2019; 34: 1746–1765).
Aims
To analyze the type of VA used by incident and prevalent KF pediatric patients (pts) treated with HD in Catalonia
Method
Data from the Catalan Renal Registry of KF pts younger than 18 years of age undergoing kidney replacement therapy (KRT) were examined for a 22-year period.
Results
The modality of KRT used by incident KF pediatric pts has changed significantly over time: the percentage of children who started KRT through HD decreased progressively from 89.9% during the 1984-1989 period to 38.2% during the 2014-2018 period and, conversely, the percentage of children who started KRT by using pre-emptive KT increased progressively from 5.1% to 42.6% between the same periods (for both comparisons, p<0.001). During 2018, 18 children started KRT (rate: 12.8 per milion of population, pmp) by using pre-emptive KT (n=8, 44.4%), peritoneal dialysis (n=5, 27.8%) or HD (n=5, 27.8%).
From 1997 to 2018, 112 KF pediatric pts started KRT by using HD (mean age 9.4±6,0 yr, male 58.9%, glomerular disease 36.8%). Most children started HD through an AVF during the 1997-2001 period (56.5%) but this percentage decreased over time and no children used an AVF for starting HD during the 2012-2018 period. On the contrary, the percentage of children starting HD through a TC increased progressively from 8.7% to 72.2% between the same periods (for both comparisons, p<0.001). No significant changes over time were recorded regarding untunnelled catheter (UC) utilization from 34.8% (1997-2001 period) to 27.8% (2012-2018 period) (p=0.57). Considering two age groups (0-6 vs 7-18 years), VA distribution was the following (%): 23.3 vs 76.7 for UC, 47.2 vs 52.8 for TC and 26.3 vs 73.7 for AVF (p=0.058). Regarding KF presentation, UC was used mainly to initiate HD in crashlanders (53.3%) and AVF was used mainly to start HD in children with steady kidney disease progression (63.2%) (p=0.003).
The KRT modality of using prevalent KF pediatric pts has also changed significantly over time: pts on HD decreased from 34.9% (n=15, mean age 13.5 yr) in 1997 to 4.7% (n=5, mean age 11.6 yr) in 2018 and, conversely, pts with a kidney graft increased from 62.8% (n=27, mean age 13.7 yr) to 92.4% (n=98, mean age 11.2 yr) during the same period (for both comparisons, p<0.001). The percentage of children dialyzed through an AVF decreased progressively from 1997 (100%) to 2018 (0%) (p<0.001). All prevalent HD pts were dialyzed through a catheter in 2018.
The KT rate increased significantly from 5.4 pmp (n=6) in 1997 to 17.1 pmp (n=24) in 2018 (p=0.007). The median time on HD (months) prior to the first KT decreased progressively from 23.1 during the 1984-1989 period to 6.6 during the 2014-2018 period (p<0.001).
Conclusions
1) The VA profile of pediatric population treated with HD in Catalonia has radically changed over time. 2) Since 2012, AVF has practically disappeared as the VA in the incident and prevalent pediatric population on HD. 3) Almost all children treated by HD since 2012 were dialyzed through a catheter due to the short waiting time before receiving a kidney graft. 4) The high KT rate was a determining factor in choosing the AV type in the pediatric population treated with HD in Catalonia.
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