1. There are three main types of vascular access for hemodialysis in children: tunneled catheters, arteriovenous fistulas, and arteriovenous grafts. 2. It is important to educate children with declining kidney function about their vascular access options and the importance of vein preservation for potential future access. 3. The choice of vascular access depends on multiple patient-specific factors and a dedicated vascular access clinic can help increase use of arteriovenous fistulas and decrease use of catheters.

1. Banafsheh Arad. MD
Pediatric Nephrologist, QUMS

2. Three principle forms of vascular access available for the treatment of
children with ESRD by hemodialysis
1. Tunneled catheters placed in a central vein (central venous lines,
CVLs)
2. Arteriovenous fistulas (AVF)
3. Arteriovenous grafts (AVG) using prosthetic or biological material

3. Informing the patient about vascular access when and
how should it begin?
Educate children with CKD Stage 4 (eGFR <30mL/min/1.73 by
Schwartz formula), and those with rapidly declining kidney
function.
At this time, in addition to the information about different RRT
techniques, the patient should receive VA-related information.

4. Importance of vein preservation for childhood ESRD
Educate children with CKD and their carer about venous preservation,
irrespective of the choice of future renal replacement therapy (RRT).
Almost all children undergoing dialysis will be considered for kidney
transplantation, as this is the optimal therapy for childhood ESRD.
However, once transplanted, 25% of children return to dialysis even
before moving to adult dialysis programs.

5. A child with ESRD has a lifetime of RRT ahead of them
The choice of optimal vascular access for an individual patient and
determining timing of access creation are dependent on a multitude of
factors that can vary widely with each patient, including;
▪ Demographics
▪ Comorbidities: Diabetes mellitus, peripheral arterial disease
▪ Anatomy
▪ Personal preferences

6. A dedicated vascular access clinic
✓This prolonged lead-in period also allows for psychological
preparation for dialysis with an AVF and helps to avoid initiating
dialysis with a CVL, which may then become difficult to convert to an
AVF later.
✓ While AVF maturation times of 2months have been reported the
overall process from preoperative assessment until the fistula is fully
operational

7. Hemodialysis vascular access options in pediatrics: Considerations for
patients and practitioners. Pediatr Nephrol (2009) 24:1121–1128
Placing AVFs in children:
weighing >20 kg
who are expected to wait >1year for a kidney transplant
Educational video for patients and families;
options for vascular access
venous preservation

8. Vascular access in children requiring maintenance hemodialysis: a consensus
document by the European Society for Pediatric Nephrology Dialysis Working
Group. Nephrol Dial Transplant (2019) 1–20
• Venipuncture above the wrist in either arm should be avoided, except
in an emergency, to preserve the forearm cephalic, antecubital and
upper arm veins.
• A pragmatic approach to balance the need for frequent blood draws
versus the need for venous preservation is required, and the
(presumed) nondominant arm may be spared for later AVF creation.
• Using the dorsal veins of both hands needs to be emphasized.

9. • Wearing of Medic alert type bracelets may be helpful in preserving
veins, by serving as a reminder for both the patient and healthcare
professional performing phlebotomy

10. NS Singh — "Save the Vein" Initiative in Children With CKD: A Quality
Improvement Study. Am J Kidney Dis. 2021 Jul;78(1):96-102.e1.
Extreme care should be
taken to preserve the
superficial venous network
of both upper limbs, which
should remain free of
needling and cannulations
in order to facilitate the
creation of an arteriovenous
fistula in patients with
advanced chronic kidney
disease.

11. A dedicated vascular access clinic
• A long-term CVL might be associated with central venous stenosis and
it may not be possible to create an AVF in the future.
• Conversion from CVL is often difficult and breaking the habit of
‘staying with what you start with’ requires great effort in time and
persuasion.
• In children after 2 years of setting up a dedicated vascular access
clinic, the percentage of children dialyzing via a CVL had decreased
from 68% to 22%

12. Vascular access guidelines:
The dominance of the upper limbs
✓Minimize the impact on daily activity
✓Avoid anticoagulant therapy
Repeated and multiple cannulations produce trauma and the
administration of medication provokes an inflammatory response at
the vein level (chemical phlebitis).

13. Contraindicated for children who have a history of renal insufficiency
or could be anticipated to require HD in the future
1. Peripherally inserted central catheters (PICC) and Midline catheters

14. 2. Subclavian venous lines Stenosis preclude use of ipsilateral arm for
vascular access

15. Central venous catheter be used in these patients
1. Acute or acute-on-chronic renal failure who require urgent vascular
access for hemodialysis
2. A non-recoverable thrombosis of an AV-fistula until a new AV-fistula
is created
3. Life expectancy less than 6 months
4. Cardiovascular condition contraindicating AV-fistula
5. Kidney transplant from living donor
6. Desire of the patient

16. Arteriovenous fistula care
Care in the immediate post-operative period
The limb with the AV fistula should be raised,
resting on a pillow to promote venous return and
prevent edema
Distal areas of the limb should be observed to
rule out signs of ischemia, such as pain, coldness,
pallor and motor and sensory changes

17. Effect of a postoperative exercise program on arteriovenous fistula
maturation: A randomized controlled trial ... Hemodial Int. 2016
Checks were performed by DU at 24 h and 2 weeks after AVF creation. Significant
increases in the diameter of the efferent vein, wall thickness, venous area and
QA were observed in the study group after exercise.
Its beneficial effects include the increase in venous diameter, as well as the
increase in muscle mass and the decrease in the amount of fat tissue.
The patient do exercises before and after the creation of native arteriovenous
fistulae to promote maturation, especially in distal accesses.

18. Ambulatory daily exercise program with flex band for 1 month after
arteriovenous fistula creation

19. Arteriovenous fistula care by the patient in the interdialytic period
Detection of possible signs and symptoms of complications
Infection: redness patches/irritations, warmth, pain and suppuration
Ischemia: coldness, pallor and pain
Thrombosis: hardening or pain, and absence of bruit and thrill
Decreased venous return: edema

20. Acquiring certain habits in order to preserve
arteriovenous fistula function
1. Blood pressure must not be taken or venipunctures
2. The AVF must not be knocked or compressed. Tight clothing,
watches, bracelets and occlusive bandages should not be worn and
the patient should not sleep on the arm of the AVF.
3. Weights must not be lifted or brusque movements made during
exercise with this arm.
4. Sudden changes of temperature must be avoided.

21. KDOQI does not suggest the use of these drugs in the perioperative
period to improve primary patency or initial use of AV access (AVF or
AVG)
• Heparin
• Clopidogrel monotherapy or Clopidogrel-prostacyclin (iloprost)
• Glyceryltrinitrate or cholecalciferol

22. Local Care in AV-Fistula
•From the first 24-48 h after AVF creation, gentle movements should be made with the
fingers and arm of the AVF to promote blood circulation, but no brusque movements
should be made when doing the exercises as they are likely to lead to bleeding from the
wound or hinder venous return. In elbow nAVF and in pAVF created in the flexure, the arm
must not be flexed.
•The dressing should be kept clean and dry at all times and changed if dirty or wet.
•In these early stages, situations that may contaminate the surgical wound are to be
avoided and, if necessary, adequate protective measures should be taken (work in the
countryside, work with animals).
•After the surgical stitches have been removed, the whole arm of the AVF should be
thoroughly cleansed with warm water and soap on a daily basis.
•When the patient has started HD therapy, the dressing covering the needling sites must
be removed the day after the HD session. If the dressing is stuck to the skin, it is advisable
to wet it with saline solution to prevent any injury which might lead to bleeding or
infection of the AVF. The scab covering the wound must never be lifted.
•If bleeding occurs through the needling hole in the skin, a gauze should be applied and
compressed gently with the fingers as in the HD session. If bleeding does not stop in a
reasonable amount of time, the patient should attend a healthcare facility for assessment.
A circular compression bandage should never be used.

23. Local Care in CVC
• The exit site of the central venous catheter and the skin of the peri-
catheter area be covered to preserve integrity and keep it dry
• Central venous catheter exit site dressing be assessed at each
hemodialysis session and changed whenever wet, stained, detached
or presents any signs of infection. If any of these conditions are not
present, we recommend it be changed once a week

24. The patient must be given instructions on:
• The need for good hygiene and how to wash daily.
• The use of appropriate clothing, avoiding elements that can cause
kinking in the CVC or rub the subcutaneous tunnel (braces, chains,
etc.).
• How to clean the exit site, if it is necessary to do so.
• Refrain from doing risky activities such as immersion baths, or
traction
• They will be given information on possible complications, their causes
and the actions that must be performed to try to avoid them.

25. • Infection: The integrity of the dressing, which should be clean, dry
and without secretion, must be examined in each HD session.
• Pain in the shoulder or neck that may indicate CVC rupture or abrupt
changes in the patient’s clinical condition that would suggest a
serious complication.
• Alterations in skin integrity: dermatitis caused by allergies to the
material used, excessive cleansing or dressings that induce
maceration of the skin and decubitus ulcers produced by the Dacron
cuff or by the CVC itself at the exit site.
• Periodic control of the length of the outer part of the CVC.
Determination of tip location

26. ‫بيماران‬ ‫برای‬ ‫وريدي‬ ‫كاتترهاي‬ ‫مراقبت‬
:
•
‫پانسمان‬
:
‫م‬ ‫از‬ ‫بايد‬ ‫دياليز‬ ‫پرستاري‬ ‫وكادر‬ ‫بيماران‬ ،‫بيمار‬ ‫جداكردن‬ ‫و‬ ‫وصل‬ ‫مراحل‬ ‫طي‬ ‫در‬
‫اسك‬
‫نمايند‬ ‫استفاده‬
.
‫گيرد‬ ‫قرار‬ ‫هوا‬ ‫معرض‬ ‫در‬ ‫نبايد‬ ‫سركاتتر‬ ‫و‬ ‫مجرا‬
.
‫ب‬ ‫سرنگ‬ ‫درپوش‬ ‫يك‬
‫ايد‬
‫بپوشاند‬ ‫را‬ ‫سركاتتر‬ ‫همواره‬
.
•
‫است‬ ‫ممنوع‬ ‫كاتتر‬ ‫طريق‬ ‫از‬ ‫تزريقات‬ ‫دياليزانجام‬ ‫جلسات‬ ‫بين‬ ‫فواصل‬ ‫در‬
.
•
‫مقايس‬ ‫در‬ ‫كاتتر‬ ‫خروج‬ ‫محل‬ ‫در‬ ‫كلونيزاسيون‬ ‫بيشتر‬ ‫منفذ‬ ‫بدون‬ ‫پالستيكي‬ ‫پانسمان‬
‫هاي‬ ‫پانسمان‬ ‫با‬ ‫ه‬
‫شود‬ ‫استفاده‬ ‫نبايد‬ ،‫خشك‬
.
•
‫گرفتن‬ ‫ودوش‬ ‫كردن‬ ‫حمام‬
:
‫گيرد‬ ‫قرار‬ ‫آب‬ ‫در‬ ‫نبايد‬ ‫هرگز‬ ‫كاتتر‬ ‫خروج‬ ‫محل‬
.
‫گرفتن‬ ‫دوش‬
‫بهتر‬
‫پانسمان‬ ‫سريع‬ ‫تعويض‬ ‫ضمن‬ ‫بخش‬ ‫در‬ ‫چون‬ ‫شود‬ ‫انجام‬ ‫دياليز‬ ‫بخش‬ ‫به‬ ‫آمدن‬ ‫از‬ ‫قبل‬ ‫است‬
‫پماد‬ ‫از‬
‫شد‬ ‫خواهد‬ ‫استفاده‬ ‫ميكروبيال‬ ‫آنتي‬
.

27. Thanks For your attention