Clinical Course Associated with Vascular Access Type in a National Cohort of Adolescents Who Receive Hemodialysis: Findings from the Clinical Performance Measures and US Renal Data System Projects

The cost of hospitalizations for treatment of hemodialysis catheter-associated blood stream infections in children: a retrospective cohort study

BACKGROUND

Hospitalization costs for treatment of hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) in adults are high. No studies have evaluated hospitalization costs for HD CA-BSI in children or identified factors associated with high-cost hospitalizations.

METHODS

We analyzed 160 HD CA-BSIs from the Standardizing Care to Improve Outcomes in Pediatric End-stage Kidney Disease (SCOPE) collaborative database linked to hospitalization encounters in the Pediatric Health Information System (PHIS) database. Charge-to-cost ratios were used to convert hospitalization charges reported in PHIS database to estimated hospital costs. Generalized linear mixed modeling was used to assess the relationship between higher-cost hospitalization (cost above 50^th percentile) and patient and clinical characteristics. Generalized linear regression models were used to assess differences in mean service line costs between higher- and lower-cost hospitalizations.

RESULTS

The median (IQR) length of stay for HD CA-BSI hospitalization was 5 (3-10) days. The median (IQR) cost for HD CA-BSI hospitalization was $18,375 ($11,584-$36,266). ICU stay (aOR 5.44, 95% CI 1.62-18.26, p = 0.01) and need for a catheter procedure (aOR = 6.08, 95% CI 2.45-15.07, p < 0.001) were associated with higher-cost hospitalization.

CONCLUSIONS

Hospitalizations for HD CA-BSIs in children are often multiple days and are associated with substantial costs. Interventions to reduce CA-BSI may reduce hospitalization costs for children who receive chronic HD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Epidemiology and Risk Factors for Hemodialysis Access-Associated Infections in Children: A Prospective Cohort Study From the SCOPE Collaborative

RATIONALE & OBJECTIVE

Infections cause significant morbidity and mortality for children receiving maintenance hemodialysis (HD). The Standardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a quality-improvement initiative aimed at reducing dialysis-associated infections by implementing standardized care practices. This study describes patient-level risk factors for catheter-associated bloodstream infections (CA-BSIs) and examines the association between dialysis center-level compliance with standardized practices and risk of CA-BSI.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Children enrolled in SCOPE between June 2013 and July 2019.

EXPOSURES

Data were collected on patient characteristics and center-level compliance with HD catheter care practices across the study period. Centers were categorized as consistent, dynamic (improved compliance over the study period), or inconsistent performers based on frequency of compliance audit submission and changes in compliance with HD care practices over time.

OUTCOME

CA-BSIs.

ANALYTICAL APPROACH

Generalized linear mixed models were used to evaluate (1) patient-level risk factors for CA-BSI and (2) associations between change in center-level compliance and CA-BSIs.

RESULTS

The cohort included 1,277 children from 35 pediatric dialysis centers; 1,018 (79.7%) had a catheter and 259 (20.3%) had an arteriovenous fistula or graft. Among children with a catheter, mupirocin use at the catheter exit site was associated with an increased rate of CA-BSIs (rate ratio [RR], 4.45; P = 0.004); the use of no antibiotic agent at the catheter exit site was a risk factor of borderline statistical significance (RR, 1.79; P = 0.05). Overall median compliance with HD catheter care practices was 87.5% (IQR, 77.3%-94.0%). Dynamic performing centers showed a significant decrease in CA-BSI rates over time (from 2.71 to 0.71 per 100 patient-months; RR, 0.98; P < 0.001), whereas no significant change in CA-BSI rates was detected among consistent or inconsistent performers.

LIMITATIONS

Lack of data on adherence to HD care practices on the individual patient level.

CONCLUSIONS

Improvement in compliance with standardized HD care practices over time may lead to a reduction in dialysis-associated infections.

Opportunities to Improve Antibiotic Prescribing in Outpatient Hemodialysis Facilities: A Report From the American Society of Nephrology and Centers for Disease Control and Prevention Antibiotic Stewardship White Paper Writing Group

Antibiotic use is necessary in the outpatient hemodialysis setting because patients receiving hemodialysis are at increased risk for infections and sepsis. However, inappropriate antibiotic use can lead to adverse drug events, including adverse drug reactions and infections with Clostridioides difficile and antibiotic-resistant bacteria. Optimizing antibiotic use can decrease adverse events and improve infection cure rates and patient outcomes. The American Society of Nephrology and the US Centers for Disease Control and Prevention created the Antibiotic Stewardship in Hemodialysis White Paper Writing Group, comprising experts in antibiotic stewardship, infectious diseases, nephrology, and public health, to highlight strategies that can improve antibiotic prescribing for patients receiving maintenance hemodialysis. Based on existing evidence and the unique patient and clinical setting characteristics, the following strategies for improving antibiotic use are reviewed: expanding infection and sepsis prevention activities, standardizing blood culture collection processes, treating methicillin-susceptible Staphylococcus aureus infections with β-lactams, optimizing communication between nurses and prescribing providers, and improving data sharing across transitions of care. Collaboration among the Centers for Disease Control and Prevention; American Society of Nephrology; other professional societies such as infectious diseases, hospital medicine, and vascular surgery societies; and dialysis provider organizations can improve antibiotic use and the quality of care for patients receiving maintenance hemodialysis.

Vascular Access and Risk of Bloodstream Infection Among Older Incident Hemodialysis Patients

Rationale & Objective

Most new patients with end-stage renal disease (ESRD) initiate hemodialysis (HD) with a central venous catheter (CVC) and later transition to a permanent vascular access with lower infection risk. The benefit of early fistula use in preventing severe infections is incompletely understood. We examined patients' first access and subsequent transitions between accesses during the first year of HD to estimate the risk for bloodstream infection (BSI) associated with incident and time-dependent use of HD access.

Study Design

A retrospective cohort study using enhanced 5% Medicare claims data.

Setting & Participants

New patients with ESRD initiating HD between January 1, 2011, and December 31, 2012, and having complete pre-ESRD Medicare fee-for-service coverage for 2 years.

Exposure

The incident and prevalent use of CVC, graft, or fistula as determined from monthly reports to the Centers for Medicare & Medicaid Services by HD providers.

Outcome

Incident hospitalization with a primary/secondary diagnosis of BSI (International Classification of Diseases, Ninth Revision, Clinical Modification code 038.xx or 790.7).

Analytical Approach

Extended survival analysis accounting for patient confounders.

Results

Of 2,352 study participants, 1,870 (79.5%), 77 (3.3%), and 405 (17.2%) initiated HD with a CVC, graft, and fistula, respectively. During the first year, the incident BSI hospitalization rates per 1,000 person-days were 1.3, 0.8, and 0.3 (P<0.001) in patients initiating with a CVC, graft, and fistula, respectively. After adjusting for confounders, incident fistula use was associated with 61% lower risk for BSI (HR, 0.39; 95% CI, 0.28-0.54; P<0.001) compared with incident CVC or graft use. The prevalent fistula or graft use was associated with lower risk for BSI compared with prevalent CVC use (HRs of 0.30 [95% CI, 0.22-0.42] and 0.47 [95% CI, 0.31-0.73], respectively).

Limitations

Restricted to an elderly population; potential residual confounding.

Conclusions

Incident fistula use was associated with lowest rates of BSI, but the majority of beneficiaries with pre-ESRD insurance initiated HD with a CVC. Strategies are needed to improve pre-ESRD fistula placement.

Care of the Pediatric Patient on Chronic Dialysis

Optimal care of the pediatric end-stage renal disease (ESRD) patient on chronic dialysis is complex and requires multidisciplinary care as well as patient/caregiver involvement. The dialysis team, along with the family and patient, should all play a role in choosing the dialysis modality which best meets the patient's needs, taking into account special considerations and management issues that may be particularly pertinent to children who receive peritoneal dialysis or hemodialysis. Meticulous attention to dialysis adequacy in terms of solute and fluid removal, as well as to a variety of clinical manifestations of ESRD, including anemia, growth and nutrition, chronic kidney disease-mineral bone disorder, cardiovascular health, and neurocognitive development, is essential. This review highlights current recommendations and advances in the care of children on dialysis with a particular focus on preventive measures to minimize ESRD-associated morbidity and mortality. Advances in dialysis care and prevention of complications related to ESRD and dialysis have led to better survival for pediatric patients on dialysis.

Interventions for treating central venous haemodialysis catheter malfunction

BACKGROUND

Adequate haemodialysis (HD) in people with end-stage kidney disease (ESKD) is reliant upon establishment of vascular access, which may consist of arteriovenous fistula, arteriovenous graft, or central venous catheters (CVC). Although discouraged due to high rates of infectious and thrombotic complications as well as technical issues that limit their life span, CVC have the significant advantage of being immediately usable and are the only means of vascular access in a significant number of patients. Previous studies have established the role of thrombolytic agents (TLA) in the prevention of catheter malfunction. Systematic review of different thrombolytic agents has also identified their utility in restoration of catheter patency following catheter malfunction. To date the use and efficacy of fibrin sheath stripping and catheter exchange have not been evaluated against thrombolytic agents.

OBJECTIVES

This review aimed to evaluate the benefits and harms of TLA, preparations, doses and administration as well as fibrin-sheath stripping, over-the-wire catheter exchange or any other intervention proposed for management of tunnelled CVC malfunction in patients with ESKD on HD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 17 August 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

We included all studies conducted in people with ESKD who rely on tunnelled CVC for either initiation or maintenance of HD access and who require restoration of catheter patency following late-onset catheter malfunction and evaluated the role of TLA, fibrin sheath stripping or over-the-wire catheter exchange to restore catheter function. The primary outcome was be restoration of line patency defined as ≥ 300 mL/min or adequate to complete a HD session or as defined by the study authors. Secondary outcomes included dialysis adequacy and adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed retrieved studies to determine which studies satisfy the inclusion criteria and carried out data extraction. Included studies were assessed for risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using GRADE.

MAIN RESULTS

Our search strategy identified 8 studies (580 participants) as eligible for inclusion in this review. Interventions included: thrombolytic therapy versus placebo (1 study); low versus high dose thrombolytic therapy (1); alteplase versus urokinase (1); short versus long thrombolytic dwell (1); thrombolytic therapy versus percutaneous fibrin sheath stripping (1); fibrin sheath stripping versus over-the-wire catheter exchange (1); and over-the-wire catheter exchange versus exchange with and without angioplasty sheath disruption (1). No two studies compared the same interventions. Most studies had a high risk of bias due to poor study design, broad inclusion criteria, low patient numbers and industry involvement.Based on low certainty evidence, thrombolytic therapy may restore catheter function when compared to placebo (149 participants: RR 4.05, 95% CI 1.42 to 11.56) but there is no data available to suggest an optimal dose or administration method. The certainty of this evidence is reduced due to the fact that it is based on only a single study with wide confidence limits, high risk of bias and imprecision in the estimates of adverse events (149 participants: RR 2.03, 95% CI 0.38 to 10.73).Based on the available evidence, physical disruption of a fibrin sheath using interventional radiology techniques appears to be equally efficacious as the use of a pharmaceutical thrombolytic agent for the immediate management of dysfunctional catheters (57 participants: RR 0.92, 95% CI 0.80 to 1.07).Catheter patency is poor following use of thrombolytic agents with studies reporting median catheter survival rates of 14 to 42 days and was reported to improve significantly by fibrin sheath stripping or catheter exchange (37 participants: MD -27.70 days, 95% CI -51.00 to -4.40). Catheter exchange was reported to be superior to sheath disruption with respect to catheter survival (30 participants: MD 213.00 days, 95% CI 205.70 to 220.30).There is insufficient evidence to suggest any specific intervention is superior in terms of ensuring either dialysis adequacy or reduced risk of adverse events.

AUTHORS' CONCLUSIONS

Thrombolysis, fibrin sheath disruption and over-the-wire catheter exchange are effective and appropriate therapies for immediately restoring catheter patency in dysfunctional cuffed and tunnelled HD catheters. On current data there is no evidence to support physical intervention over the use of pharmaceutical agents in the acute setting. Pharmacological interventions appear to have a bridging role and long-term catheter survival may be improved by fibrin sheath disruption and is probably superior following catheter exchange. There is no evidence favouring any of these approaches with respect to dialysis adequacy or risk of adverse events.The current review is limited by the small number of available studies with limited numbers of patients enrolled. Most of the studies included in this review were judged to have a high risk of bias and were potentially influenced by pharmaceutical industry involvement.Further research is required to adequately address the question of the most efficacious and clinically appropriate technique for HD catheter dysfunction.

Variation in estimated glomerular filtration rate at dialysis initiation in children

BACKGROUND

Data guiding the timing of dialysis initiation in children are limited. We sought to determine current practice and secular trends in Canada with respect to the timing of dialysis initiation in children based on estimated glomerular filtration rate (eGFR).

METHODS

This observational study included incident chronic dialysis patients aged ≤21 years identified from the Canadian Organ Replacement Register who started dialysis in Canada between January 2001 and December 2010 at any of the nine participating Canadian centers (n = 583). Youth were categorized utilizing CKiD Schwartz eGFR into ≥10.5 (higher) or <10.5 ml/min/1.73 m² (lower) eGFR groups. Differences at dialysis initiation by facility and region were examined, and secular trends were determined.

RESULTS

Median eGFR at dialysis initiation was 8.1 (interquartile range 5.4-11.0) ml/min/1.73 m². Overall, 29 % of the patients started dialysis with an eGFR of ≥10.5 ml/min/1.73 m². The proportion of children starting with higher eGFR increased from 27.3 % in 2001 to 35.4 % in 2010 (p = 0.04) and differed by treatment facility (12-70 %; p = 0.0001). Factors associated with higher eGFR at dialysis initiation in the adjusted regression model were female sex [odds ratio (OR) 1.48; 95 % confidence interval (CI) 1.02-2.14], genetic cause of end-stage kidney disease (OR 2.77; 95 % CI 1.37-5.58) and living ≥50 km from treatment facility (OR 1.47; 95 % CI 1.01-2.14).

CONCLUSIONS

One-third of the children were found to have initiated dialysis with an eGFR ≥10.5 ml/min/1.73 m², however significant practice variation exists with respect to timing of dialysis initiation by treatment facility. More data is required to evaluate the clinical implications of this practice variation.

Chronic Hemodialysis in Small Children

When peritoneal dialysis is inapplicable, chronic hemodialysis (HD) becomes the only available treatment option in small children. Due to small patient size, central venous catheters (CVC) are mainly used for vascular access. Over the past 4 years, four children weighing less than 15 kg received chronic HD in our unit. A total of 848 dialysis sessions were performed. Altogether, 21 catheters were inserted. In all but one occasion, uncuffed catheters were used. Catheter revision was performed 15 times during the study period, either due to infection or catheter malfunction. The median number of catheter revisions and the median line survival was 3.0/patient-year and 53 days (range; 6-373 days), respectively. There were 14 episodes of catheter related infections requiring 11 CVC revisions (78.6%). The median rate of line infections was 2.8/patient-year. Chronic HD in small children is demanding and labor intensive. Issues pertain mainly to CVCs and limit its long-term use.

Vascular access for chronic hemodialysis in children: arteriovenous fistula or central venous catheter?

BACKGROUND

The choice of vascular access (VA) for hemodialysis (HD) in end-stage renal disease (ESRD) is arteriovenous fistula (AVF) or central venous catheter (CVC). Whereas clinical practice guidelines suggest AVF to preserve the vascular bed, pediatric nephrologists tend to favor CVC for shorter-term dialysis. Our objective was to determine whether pediatric priority allocation policies for deceased-donor kidneys affect VA planning.

METHODS

Pediatric priority for deceased-donor kidneys was instituted in Quebec in 2004. We retrospectively compared clinical practice on AVF, CVC, wait time on transplant list, HD duration in pre-policy (group A) and post-policy (group B) from 1997-2011.

RESULTS

We identified 78 patients with a median age of 14.7 years (range, 0.7-20.5 years) and weight of 46 kg (12.5-95 kg); AVF decreased from 76 % in group A to 41 % in group B (p = 0.002). Wait times on transplant list were significantly reduced: median 413.5 days (range, 2-1,910 days) in group A vs. 89 days (range, 18-692 days) in group B (p = 0.003). Time on HD for deceased-donor recipients was shorter: 705 (range, 51-1,965 days) group A vs. 349.5 days (range, 158-1,060 days) group B (p = 0.01).

CONCLUSIONS

This is the first study to document VA changes related to pediatric priority allocation policy. Our fistula-first center saw a shift toward CVC-first.

Reducing central venous catheters in chronic hemodialysis--a commitment to arteriovenous fistula creation in children

BACKGROUND

An internal permanent vascular access [arteriovenous fistula (AVF) or arteriovenous graft (AVG)] is preferred over central venous catheters (CVC) for chronic hemodialysis. However, CVC remain the most commonly used access in children. The objective of this study was to evaluate our experience with AVF.

METHODS

We conducted a retrospective chart review of children aged 1-18 years on chronic hemodialysis from 2001 to 2012. Patients were divided into three time periods: 2001-2005, 2006-2009 and 2010-2012. A systematic approach to AVF placement was introduced in our department in 2006 which resulted in a greater number of AVF being placed and used, but the access failure rate was still higher than desired. In 2010, a more experienced vascular surgeon was contacted to perform AVF surgery in our most difficult AVF candidates.

RESULTS

Sixty-five AVF were created in 55 patients (67.3 % male). The median age of the patients was 14 (3-18) years. Forty-one (63.1 %) AVF were used successfully, and this number increased from 52.6 to 57.6 to 92.3 % over the three time periods, respectively. Over time, AVF use rates increased and CVC use decreased. By 2012 only 7.7 % of our patients were using a CVC. The primary patency rate was 42.9 % at 1 year; secondary patency rates were 100 and 93.8 % at 1 and 2 years, respectively. Infection and hospitalization rates were higher for CVC than for AVF [0.8 vs. 0.1 infections per access-year (p < 0.001) and 0.9 vs. 0.2 hospitalizations per access-year (p < 0.001)].

CONCLUSIONS

With a dedicated approach and vascular access team it is possible to decrease CVC and increase AVF use in children on hemodialysis. In our study, increased AVF use resulted in decreased access-related infection and hospitalization rates.

No difference in meeting hemoglobin and albumin targets for dialyzed children with urologic disorders

Urologic disorders are the most common cause of chronic kidney disease in children. To determine whether children with urologic etiology of end-stage renal disease (ESRD) fare better than children with ESRD from other causes while on dialysis, we conducted a cross-sectional study of children <18 years receiving peritoneal and hemodialysis in the United States using data from the Centers for Medicare & Medicaid Services 2005 ESRD CPM Project. We compared baseline demographics and the study groups. In multivariate logistic regression analysis of 1,286 subjects, we assessed whether children with urologic disorders had a higher odds of meeting adult KDOQI targets for hemoglobin levels ≥11 g/dl and albumin ≥3.5 BCG/3.2 BCP g/dl. We conducted a subset analysis of 1,136 patients to examine the impact of erythropoietin on hemoglobin targets. Our results did not reveal differences in achievement of adult hemoglobin targets (adjusted OR: 1.27; p value 0.09; CI: 0.97-1.66) or in the subset analysis with erythropoietin (adjusted OR: 1.32; p value 0.06; CI: 0.98-1.78) or albumin targets (adjusted OR: 1.22; p value 0.21; CI: 0.90-1.65) in adjusted analyses. Due to our study's limitations, it is difficult to determine whether this may result from treatment prior to dialysis initiation or treatment effect of dialysis rather than underlying diagnosis.

Preventing catheter-related infections in children undergoing hemodialysis

The increased use of tunneled cuffed catheters in children on chronic hemodialysis is the result of their relative ease of insertion, pain-free dialysis and immediate use. The disadvantage of their use is that they are associated with catheter-related bacteremia (CRB), which in turn is related with increased morbidity, access loss and occasionally metastatic infections and even death. A CRB might be difficult to diagnose and is often associated with a previous history of CRB, exit-site infection, low serum albumin and long duration of catheter use. There is evidence that the use of arteriovenous fistulae is associated with lower infection rates. The implementation of effective strategies for the prevention of CRBs include the adoption of policies for improving arteriovenous fistula rates, appropriate surgical catheter insertion and optimal nursing care of the exit site, and a safe connection technique. Recently, the effectiveness of antimicrobial catheter solutions for preventing CRB has been documented in a number of randomized clinical trials. In addition, the application of antibiotic ointments at the exit sites of tunneled cuffed catheters might be significant for the reduction of Staphylococcus-related CRB. The upside is that education-based programs combining specific preventive measures can significantly reduce CRBs.

Low infection rates and prolonged survival times of hemodialysis catheters in infants and children

BACKGROUND AND OBJECTIVES

Hemodialysis (HD) catheter-related complications are regarded as the main cause of HD failure in infants and children with ESRD. In this study, we determined HD catheter infection rates and survival times in children.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We analyzed demographic, clinical, laboratory, and microbiologic data on all infants and children with ESRD who received HD therapy through a tunneled central venous catheter (CVC) in our Pediatric Dialysis Unit between January 2001 and December 2009. Our strict care of HD-CVCs makes no use of any kind of prophylactic antibiotic therapy.

RESULTS

Twenty-nine children with ESRD (median age, 10 years) received HD through a CVC, for a total of 22,892 days during the study period. Eleven (38%) children were infants (<1 year of age) who received HD for a cumulative 3779 days (16% of total). Fifty-nine CVCs were inserted, of which 13 (22%) were in infants. There were 12 episodes of CVC infection-a rate of 0.52/1000 CVC days. Four (33%) episodes occurred in infants-a rate of 1.06/1000 CVC days. Only three (5%) of the CVCs were removed because of infection. Median catheter survival time for all children was 310 days and for infants was 211 days.

CONCLUSIONS

Very low CVC infection rates (one infection per 5 CVC years) and prolonged CVC survival times (around 1 year) are achievable in infants and children with ESRD receiving HD therapy by adhering to a strict catheter management protocol and without using prophylactic antibiotic therapy.

Hospitalization rates and clinical performance measures in U.S. adolescent hemodialysis patients

The Centers for Medicare and Medicaid Services' End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project monitors clinical measure attainment in pediatric hemodialysis (HD) patients. Targets include hemoglobin ≥ 11 g/dL, albumin ≥ 3.5/3.2 g/dL (bromcresol green/purple), single-pooled Kt/V ≥ 1.2, and the use of subcutaneous access. We hypothesized that the achievement of multiple targets by adolescent HD patients is associated with decreased morbidity. Data on patients aged 12-18 years included in the ESRD CPM Project from 2000 to 2004 with Medicare as primary payer were linked to the U.S. Renal Data System data from October 1, 1999 to December 31, 2004. Hospitalization rates by number of targets achieved were determined with Poisson regression analysis adjusted for dialysis vintage, short stature, and race. A total of 1534 patients with 1774 patient-years of follow-up, with 580 hospitalizations, were included in the analysis. In their first year in the ESRD CPM Project, 22% of the patients achieved four targets, with 34 and 28% achieving three and two targets, respectively. Subcutaneous access was least frequently attained target; spKt/V ≥ 1.2 was the most frequently attained target. After adjustment, there was decreased hospitalization risk with increasing target attainment (incidence rate ratio 0.74, 95% confidence interval 0.67-0.80, p < 0.001). Based on this analysis, meeting adult-defined targets is associated with decreases in the hospitalization rate of adolescent HD patients. Tracking adult-defined HD measures is appropriate for assessing hospitalization risk in adolescent patients, although no evidence for a cause-and-effect relationship exists.

Prevention of catheter-related bacteremia in children on hemodialysis: time for action

This editorial commentary discusses the strategies for prevention of catheter-related bacteremia (CRB) in children on hemodialysis, which is associated with high morbidity and the increase of hospital cost. There is evidence that the use of arteriovenous fistulae in children on hemodialysis is associated with lower infection rates. Therefore, the use of catheters in these patients should be decreased by improving arteriovenous fistulae use rates or by increasing peritoneal dialysis patient recruitment. However, despite the wide adoption of such policies, hemodialysis catheters are still being used in a significant number of cases. For these patients, implementation of effective strategies for preventing contamination of the catheter hub should be a priority. The appropriate recording and evaluation of CRB rates are important for assessing preventive policies. In addition, the successful management of a CRB is essential for preventing recurrence of bacteremia. Recently it was documented in a number of randomized clinical trials that antimicrobial lock solutions were effective for preventing CRB. It is suggested that the use of antimicrobial locks should be considered in children who are at high risk of developing CRB, with caution for their long-term use, because of the possibility of bacterial resistance. Now is the time for action, and all preventive steps should be performed simultaneously to minimize the risk of CRB.

Clinical outcomes in pediatric hemodialysis patients in the USA: lessons from CMS' ESRD CPM Project

Although prospective randomized trials have provided important information and allowed the development of evidence-based guidelines in adult hemodialysis (HD) patients, with approximately 800 prevalent pediatric HD patients in the United States, such studies are difficult to perform in this population. Observational data obtained through the Center for Medicare & Medicaid Services' (CMS') End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project have allowed description of the clinical care provided to pediatric HD patients as well as identification of risk factors for failure to reach adult targets for clinical parameters such as hemoglobin, single-pool Kt/V (spKt/V) and serum albumin. In addition, studies linking data from the ESRD CPM Project and the United States Renal Data System have allowed evaluation of associations between achievement of those targets and the outcomes of hospitalization and death. The results of those studies, while unable to prove cause and effect, suggest that the adult ESRD CPM targets may assist in identifying pediatric HD patients at risk for poor outcomes.

Vascular access complications in long-term pediatric hemodialysis patients

Current data demonstrate pediatric patients who remain on hemodialysis (HD) therapy are more likely to be dialyzed via central venous catheters (CVCs) than arteriovenous grafts (AVGs) and fistulae (AVFs). We retrospectively compared complications and health-related quality of life (HRQOL) associated with different vascular access types at two large centers over a 1-year period. Patients included in the study were younger than 25 years of age, weighed >20 kg, and had received HD for at least 3 months. Thirty CVC patients and 21 AVG/AVF patients received a total of 2,393 and 3,506 HD treatments, respectively. The infectious complication rate was higher for CVC patients, who were hospitalized 3.7 days for each 100 HD treatments versus 0.2 days for AVG/AVF patients (p < 0.01). CVC patients also had a much higher rate of access revision, needing 2.7 hospital days every 100 HD treatments compared with 0.2 days for AVG/AVF patients (p < 0.01). HRQOL scores did not differ between groups. Thus, despite similar HRQOL, CVCs were associated with more complications and greater morbidity when compared with AVG/AVFs. These findings further emphasize the need to use AVG/AVFs as primary HD access for pediatric patients expected to receive a long course of maintenance HD.

Patterns of use of vascular catheters for hemodialysis in children in the United States

BACKGROUND

Arteriovenous fistulas (AVFs) and grafts (AVGs) have been associated with improved clinical outcomes in children and adults with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) therapy, but use of vascular catheters is high. Identifying the reasons for the high prevalence of vascular catheters in children on HD therapy is necessary to assess whether targeted interventions may increase the prevalence of AVFs/AVGs.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Children younger than 18 years on HD therapy in the 2001 to 2003 ESRD Clinical Performance Measures (CPM) Projects followed up in the US Renal Data System transplant files through December 31, 2004.

PREDICTOR

Vascular access type and reasons for use of a vascular catheter.

OUTCOMES & MEASUREMENTS

Demographic/clinical characteristics, including the reason provided for use of a vascular catheter, and the association of type of vascular access and (1) patient size and (2) time to kidney transplantation.

RESULTS

Of 1,284 prevalent pediatric CPM patients examined, 529 (41%) had an AVF/AVG and 755 (59%) had a vascular catheter. Of 755 children with a catheter, "small body size" was a commonly listed reason (N = 142); 49% of these children weighed 20 kg or more. Of 53 patients with catheters described as having an "AVF/AVG maturing" and present in the consecutive ESRD CPM project year, 64% had a functioning AVF/AVG the following year. For those with "transplantation scheduled" listed as a reason for a vascular catheter (N = 83), 69% underwent transplantation within 1 year, and median time to transplantation was 115 days. Of all children with vascular catheters (N = 755), 32.2% underwent transplantation within 1 year, and median time to transplantation was 264 days compared with 21.7% and 347 days for those with AVFs/AVGs, respectively (N = 529). Of the 445 incident children in this cohort, 89% had a vascular catheter at dialysis therapy initiation.

LIMITATIONS

Because of study design, only associations can be described.

CONCLUSIONS

Vascular catheter use in children on HD therapy is high. This is partially explained by expeditious transplantation and technical barriers to AVF/AVG placement in small children; however, only one-third of patients with a vascular catheter underwent transplantation within 1 year. Interventions to decrease vascular catheter use in this population may be necessary.

Reduced albumin levels and utilization of arteriovenous access in pediatric patients with systemic lupus erythematosus (SLE)

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects between five and ten thousand children in the USA. Kidney disease may progress to end-stage renal disease (ESRD) and subsequent need for dialysis therapy in a significant number of children with SLE. We performed a cross-sectional analysis comparing achievement of National Kidney Foundation/Kidney Disease Outcomes Quality Initiative clinical targets in pediatric patients with SLE maintained on hemodialysis (HD) to pediatric patients with other causes of ESRD. Ninety-seven unique SLE patients and two control groups-1,823 unique pediatric patients with other causes of ESRD and 694 pediatric patients with glomerulonephritis-were identified in the End Stage Renal Disease Clinical Performance Measures 2000-2004 Project Years. SLE patients were older, with a female and black race predominance compared with both control groups. Pediatric patients maintained on HD secondary to SLE were less likely to meet albumin targets and more likely to have vascular catheters than were pediatric patients on HD secondary to other causes. These findings may be associated with increased morbidity and mortality in pediatric patients with SLE maintained on HD and deserve further study.