- Email: [email protected]
Creating arteriovenous fistulas for children in Guatemala
Creating arteriovenous fistulas for children in Guatemala William C. Jennings, MD,a Randall Lou-Meda, MD,b Nasir Mushtaq, PhD, MBBS, MPH,c Alexandros Mallios, MD,d Sindy Méndez-Soveranis, MD,b Raúl Ernesto Sosa Tejada, MD,e John F. Lucas III, MD, FACS,f and Wayne S. Gradman, MD,g Tulsa, Oklahoma; Guatemala City, Guatemala; Paris, France; Greenwood, Miss; and Beverly Hills, Calif
ABSTRACT Objective: The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. Methods: Three surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions. Results: AVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 6 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 6 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 6 2.9 kg/m2). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications. Conclusions: Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months. (J Vasc Surg 2019;-:1-7.) Keywords: Arteriovenous fistula; Children; Pediatric; Hemodialysis; Vascular access; Medical mission
The Guatemalan Foundation for Children with Kidney Diseases (FUNDANIER) was established in 2003 by pediatric nephrologist Randall Lou-Meda, MD, as the first and only comprehensive pediatric nephrology program and
From the Department of Surgery, The University of Oklahoma, College of Medicine, Tulsaa; the Servicio de Nefrología, Hipertensión, Diálisis y Trasplante, Departamento de Pediatría, Hospital Roosevelt/FUNDANIER, Guatemala Cityb; the Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Tulsac; the Vascular Surgery Department, Institut Mutualiste Montsouris, Parisd; the Department of Pediatric Surgery, Roosevelt Hospital, Mariano Galvez University, Guatemala Citye; the Department of Surgery, Greenwood Leflore Hospital, Greenwoodf; and Private Practice, Beverly Hills.g Author conflict of interest: none. Correspondence: William C. Jennings, MD, Department of Surgery, The University of Oklahoma, College of Medicine, Tulsa, 1919 S Wheeling, Ste 600, Tulsa, OK 74104-2512 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.02.022
hemodialysis unit for children in Guatemala.1 Bridge of Life (BOL) is a not-for-profit charitable organization with expertise in chronic kidney disease (CKD) and was instrumental in supplying equipment, support, training, and expertise during formation and later maintenance of the hemodialysis unit.2 Cuffed dialysis catheters were not generally available at that time; therefore, noncuffed, nontunneled catheters provided almost all vascular access (VA). In addition, catheters were placed without ultrasound guidance due to limited access to ultrasound units and ultrasound catheter insertion training, resulting in many subclavian vein access sites used instead of the more desirable internal jugular vein approach. As the pediatric dialysis unit became firmly established, FUNDANIER requested BOL assistance in establishing a VA surgical program. BOL responded by leading their established team of experienced VA surgeons to create safe and functional arteriovenous fistulas (AVF) in these children. The BOL surgical AVF missions provide a full range of VA options, working with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships, fostering continued 1
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interaction, consultations, and return visits. This study analyzes the initial experience of the BOL pediatric VA missions to Guatemala.
ARTICLE HIGHLIGHTS d
d
METHODS The medical records of all patients who underwent a VA operation in Guatemala by the BOL surgical team were reviewed retrospectively. Preoperative evaluations were carried out by the BOL surgeons in conjunction with the Guatemalan pediatric nephrology and pediatric surgical teams. After physical examination, each patient underwent an ultrasound examination with vessel mapping by the BOL surgeons.3 An outflow vein diameter of 2.0 mm or greater was acceptable if the ultrasound examination showed a normal, compliant conduit without evidence of thickening or stenosis. Similarly, arterial inflow was deemed adequate when the intraluminal vessel diameter was 1.5 mm or greater. Other modes of ultrasound evaluation such as duplex imaging were used when clinically helpful. A radiocephalic AVF (RC-AVF) at the wrist was the first choice when possible.4,5 The RC-AVF configuration was selected by anatomical considerations with a side-to-side anastomosis when feasible, closing the distal outflow after completion. Mobilization of the radial artery while leaving the cephalic vein largely undisturbed was also favored when possible. Sutures used included Gore CV8 (W. L. Gore, Newark, Del) and polypropylene 7-0 and 6-0. Interrupted sutures were often used at the proximal portion of the anastomosis in smaller vessels. The second choice was generally a proximal radial artery (PRA) inflow fistula and a brachial artery inflow AVF was created when a distal anastomosis was not feasible.6,7 A femoral vein access was used when no upper extremity access was possible by clinical evaluation, such as a history of multiple bilateral subclavian vein catheters and failed further attempts at catheter placement, now with a femoral catheter, arm or face swelling after multiple subclavian catheters, or a failed previous AVF with arm swelling.8 When creating a brachial or femoral artery inflow AVF, care was taken to limit the size of the anastomosis in relation to the artery diameter.3,9 A primary AVF transposition was performed when direct AVF options were not available.8,10 AVFs that would necessitate a later staged transposition or other staged procedure were avoided in this setting. BOL surgeons were cognizant of the need to establish a safe AVF that would be expected to mature without intervention. Balloon angioplasty for maturation would not be available and surgical intervention for pediatric VA patients was in the process of being established with the Guatemalan surgical team with the option of staged transpositions expected for future missions.11 An individual Guatemalan pediatric surgeon with interest in VA (R.S.) was fully involved and participated in each mission, in addition to spending additional time and training with one of the BOL surgeons (A.M.) at
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Type of Research: Retrospective cohort study Key Findings: Pediatric vascular access missions to Guatemala treated 54 new patients, with primary and cumulative arteriovenous fistula (AVF) patencies of 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. AVF surgical and ultrasound skills, techniques, and options were exchanged with pediatric surgeons in addition to educational sessions for other physicians, nurses, and dialysis caregivers. Take Home Message: These pediatric surgical vascular access missions created safe and functional AVFs while working in a collaborative and teaching environment with local pediatric surgeons, nephrologists, and dialysis nurses, establishing long-term collegial relationships.
his institution. During subsequent missions, three additional surgeons from the group practice of fellowshiptrained pediatric surgeons have participated. The AVFs in this report were constructed during the BOL missions. The Guatemalan surgical team progressed during this time period from learning and assisting in surgery to undertaking primary and independent surgical procedures. The timing for initial cannulation was reviewed with the pediatric nephrology and dialysis teams and a 4- to 6-week period of observation was planned for AVF maturation.12 The operations were performed at the University of San Carlos School of Medicine associated Roosevelt Hospital in Guatemala City. Anesthesia was generally provided by laryngeal mask supplemented with local anesthetic; endotracheal intubation was avoided in most cases. Sedation with local anesthetic was appropriate for some patients. Prophylactic antibiotics and systemic heparin were not used routinely.13,14 Loupe visual magnification (3.3 5.0) was used during the operations. Patient follow-up was obtained through the pediatric nephrology and pediatric surgical attending physicians, fellows, and dialysis staff. Primary AVF patency was defined as the time (months) of uninterrupted patency and without intervention. Cumulative (secondary) patency was the period from the original AVF construction, regardless of interventions or thrombosis until completion of the study period, abandonment of the access, loss to follow-up, or death. A nonfunctional AVF was considered a failed access in the analysis. All operations were performed in association with the Guatemalan pediatric surgical attending physicians, fellows, and surgical residents. Each mission involved an exchange of surgical knowledge and teaching before, during, and after the procedures. In addition, didactic sessions and cannulation training for physicians,
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Table. Characteristics of the study participants and their association with primary and cumulative patency (n ¼ 54) Patency HR (95% CI) Variable
No. (%)
Primary
Cumulative
Age
13.35 6 2.83
0.94 (0.78-1.13)
1.03 (0.80-1.32)
Height (cm)a
131.21 6 12.42
0.98 (0.93-1.02)
0.99 (0.94-1.05)
Weight (kg)a
30.78 6 8.32
0.96 (0.90-1.02)
0.98 (0.90-1.07)
17.95 6 2.85
0.98 (0.82-1.17)
1.03 (0.81-1.31)
Female
25 (46.30)
1.15 (0.41-3.21)
0.36 (0.07-1.78)
Male
29 (53.70)
Reference
a
a
BMI
Gender Reference
Cause of renal failure Undetermined
38 (70.37)
Reference
Reference
Uropathy
13 (24.07)
2.58 (0.91-7.30)
3.20 (0.80-12.80)
Hypoplasia
2 (3.70)
e
e
IGA nephropathy
1 (1.85)
e
e
Dialysis catheters 0 1-2
4 (7.41)
e
e
17 (31.48)
Reference
Reference
3-4
17 (31.48)
1.68 (0.40-7.05)
1.54 (0.26-9.21)
$5
16 (29.63)
2.75 (0.71-10.65)
1.73 (0.29-10.39)
Operation Radiocephalic
21 (38.89)
Reference
Reference
Proxradial
12 (22.22)
0.44 (0.05-4.28)
1.77 (0.11-28.34)
5 (9.26)
3.50 (0.58-21.17)
4.06 (0.25-64.92)
16 (29.63)
4.04 (1.09-15.02)
7.29 (0.85-62.45)
Brachial Transposition
BMI, Body mass index; CI, confidence interval; HR, hazard ratio. Blank spaces indicate too few patients for analysis. a For age, height, weight, and body mass index, mean 6 standard deviations are reported as descriptive statistics.
nurses, and other care providers were provided separately. A life-table analysis was performed to obtain KaplanMeier plots and to evaluate overall patency rates at different time points. Univariate and multivariable association between primary patency and cumulative AVF patency rates and patient demographic variables were examined by Cox proportional hazards models. Hazard ratio (HR) and 95% confidence intervals (CIs) were calculated. Data were analyzed with SAS version 9.4 software (SAS Institute, Cary, NC), and significance of differences was set at P < .05. This study was approved by the ad hoc research ethics committee at FUNDANIER. Informed consent was not required.
RESULTS Three surgical pediatric VA missions were conducted in Guatemala with plans for continued assistance in the future. Each mission was approximately 1 week. The initial series of children were cared for in September 2015, the second group in November 2016, and the third group in December 2017. These missions were of equivalent durations and had similar patient numbers and characteristics. A total of 54 consecutive new pediatric
patients had a VA created, all were autogenous AVFs. The patient ages were 8 to 19 years (13.4 6 2.8 years) and 29 (54%) were male. Patient weights were 28 to 50 kg (30.8 6 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 6 2.9 kg/m2). The Table shows the characteristics of the study participants and their association with primary and cumulative patency. Radiocephalic AVFs were created in 21 children (39%); three of these were mid-forearm fistulas. AVFs were established using the PRA in 12 patients (22%) and the brachial artery in 5(9%). Bidirectional PRA-AVF flow was established in three patients. Sixteen patients required a transposition (30%). Twelve transpositions used the basilic vein in the arm and two in the forearm, all completed as a singlestage procedure. The femoral vein was used for a transposition in the thigh in one patient and harvested for translocation in a second individual. Only four patients had not required a previous dialysis catheter, whereas 23 children (43%) had a history of three or more catheters. The majority of catheters were placed through the subclavian vein. Eight AVFs failed during the study period (range, 1-9 months). Four of these children with a failed new AVF had a later access created including one graft. Two of these were successful, although all were
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Fig. Kaplan-Meier vascular access (VA) patency curves show primary and cumulative (secondary) patency during the study period. The number of patients at risk, patency rates, and standard errors are shown.
considered as failed in the study patency calculation. Primary patency and cumulative patency were 83% and 85% at 12 months, 68% and 85% at 24 months, and 62% and 85% at 36 months, respectively (Fig). The median follow-up was 17 months (range, 1-36 months). Cox regression analysis found that several preoperative characteristics influenced AVF primary and cumulative patency. Patients with a history of five or more dialysis catheters had a lower primary and cumulative patency compared with those children with one or two catheters (HR, 2.75 [95% CI, 0.71-10.65]; HR, 1.73 [95% CI, 0.29-10.39], respectively). The cause of renal failure was unknown for most individuals (70%); however, those patients with obstructive uropathy had worse primary and cumulative patency rates overall. Female children had higher cumulative patency than males (HR, 0.36; 95% CI, 0.36-1.78). Patient age, height, and weight did not influence patency rates. An analysis of operative procedures was performed by grouping inflow sites for direct AVFs as radiocephalic, PRA, and brachial artery while adding a fourth group for transposition procedures. PRA-AVFs demonstrated the highest primary patency (HR, 0.44; 95% CI, 0.05-4.28), whereas radiocephalic AVFs proved to have the best cumulative patency. The Table shows all preoperative factors as covariates in patency calculations.
There were no operative deaths or major complications. However, three patients were returned to the operating room by the BOL surgical team for access dysfunction. One patient required the evacuation of a hematoma, another underwent access thrombectomy, and a third AVF was revised due to low flow; all recovered without incident and maintained functioning AVFs. These operations were considered primary failures for patency calculations. Four patients required a later operation by the Guatemalan pediatric surgical team (R.S.), one for the successful repair of a venous outflow cannulation aneurysm and with two others undergoing revision for radiocephalic inflow stenosis. A fourth child with brachial artery inflow developed a high-output AVF and underwent successful banding for flow reduction. An additional patient with an upper arm AV graft created elsewhere in Guatemala had severe arm swelling with an eroding pseudoaneurysm and bilateral subclavian vein occlusions from past catheters. Retrograde flow into large forearm veins maintained the graft patency. The graft and aneurysm were resected. No access opportunities were present in the contralateral arm; therefore, a low-flow distal radiocephalic AVF was created in the ipsilateral arm using a matured vein and successful cannulation was possible the following day. However, arm swelling eventually returned, requiring AVF ligation.
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During the second BOL mission, a child with a primary basilic vein transposition created during the initial mission had a high-grade proximal swing-site outflow stenosis that was successfully bridged proximal to the cannulation zone with a short PTFE (Gore, Flagstaff, Ariz) graft segment. During the third mission two previous BOL patients underwent successful dysfunctional AVF repair with preservation of uninterrupted dialysis access. Each had an RC-AVF with poor inflow secondary to juxta-anastomotic stenosis. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage. Seven patients died during the study period owing to causes unrelated to AVF access and with functional fistulas. FUNDANIER established a pediatric renal transplantation program in 2007 and 88 patients have received a kidney transplant. Among the children with an AVF created by BOL surgeons, four have been successfully transplanted and remain well. The AVFs in these children are asymptomatic with moderate flow and have not been ligated.15,16 These AVFs are being followed and evaluated clinically.
DISCUSSION The population of the Republic of Guatemala is approximately 16 million people. It has been estimated that 400 children develop CKD annually in Guatemala associated with reflux nephropathy, chronic glomerulonephritis, or neurogenic bladder as the leading causes of CKD in these patients.17 Many individuals in rural areas of Guatemala lack access to specialized healthcare facilities with delays in referral for diagnosis and treatment of CKD and end-stage renal disease (ESRD), possibly resulting in an under-reporting of the true incidence and prevalence of kidney disease.18 The prevalence worldwide of childhood renal replacement therapy in 2008 was 18 to 100 per million.19 Although the most common causes of childhood ESRD in developed countries are congenital disorders, acquired illnesses are more common in developing countries. The survival rate of children with ESRD overall is roughly 30 times lower than that of healthy children.19 The National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines recommends a permanent VA for children when hemodialysis is anticipated for 1 year or longer and when peritoneal dialysis (PD) or kidney transplantation is not available.20 As in adults, when hemodialysis is necessary in children, an autogenous VA is widely recommended. AVFs are associated with lower mortality and serious morbidity such as infection, access failure, and hospitalizations.21,22 These complications are more likely with grafts and particularly more likely with central venous catheter dialysis access. The National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines and the Fistula First programs have been associated with a dramatic rise in successful autogenous
access creation.20,22 AVF prevalence in children has also increased substantially over the last 10 years, although pediatric hemodialysis in United States represents only 2% of the patients receiving dialysis therapy.6,23-25 A total of 1462 children in the United States began ESRD care in 2013 with 9921 children treated for ESRD at years end, compared with 468,000 adults undergoing treatment for ESRD.25 The most common initial ESRD treatment modality among children in the United States overall was hemodialysis (56%).25 PD is often the preferred dialysis modality for children in the United States when feasible, particularly in younger individuals. However, hemodialysis is increasingly selected for chronic dialysis and a majority of children requiring dialysis will need a permanent hemodialysis access. Causes of technical PD failure include repeated PD infections, previous abdominal surgery with adhesions, or a lack of adequate ultrafiltration for dialysis. Chronic PD in children may also be associated with hypertension and left ventricular hypertrophy from volume overload.26 A 2014 public health study of children in Guatemala with CKD found 175 patients receiving continuous ambulatory PD.27 However, accessibility and an acceptable environment for PD are not universally available in Guatemala. When hemodialysis is required, a permanent access allows children more normal activities and lifestyle, as opposed to central venous catheter dialysis. Establishing a functional AVF in children has been shown to be readily attainable in young patients and both procedures and cannulation aspects are well-tolerated.6,23,24,28 The median age of the children in this study was 13 years; however, the children’s size was quite small as evidenced by the mean height of 131 cm and mean weight of 30.8 kg. Although vessel sizes were not recorded in our database, veins 2 mm or larger and arteries 1.5 mm or greater in diameter were used successfully to create functional AVFs. Bourquelot et al29 has reported an extensive experience and successful AVF outcomes with use of an operative microscope in children, while other authors access outcomes with an operating microscope for VA have been more modest.30 Our practice has been to use loupe magnification of 3.3 to 5.0 times.6,23,24,31 Percutaneous intervention with balloon angioplasty for access salvage and maturation is readily available in the United States and Europe and may have resulted in higher cumulative patency for the AVF patients in this study, but was not an option for the pediatric dialysis patients during the study period. Recently, the Guatemalan pediatric surgeons have engaged the pediatric cardiologist Guatemalan Cardiovascular Unit to aid with percutaneous intervention and advanced imaging options for future pediatric dialysis patients. Similarly, staged basilic vein transposition procedures were not used in these initial patients, but we expect this option to be available in the future.11
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In the United States, children undergo renal transplantation sooner than adults and a 6- to 12-month period of catheter dialysis may be appropriate. Pediatric renal transplantation in Guatemala through FUNDANIER is becoming more common and, although the program is relatively new, has shown very promising results. Almost all pediatric transplanted kidneys in Guatemala are currently from living-related donations and the limitation on organ availability may influence the decision of when to establish a permanent dialysis access. Regardless of the decision concerning timing of a new access, ultrasound vessel mapping to determine the best site for a VA should be performed and the patient and family educated to protect the recommended venous outflow site from cannulation and intravenous infusion. Even when PD is selected, we recommend vessel mapping for all patients to identify and preserve the most favorable AVF site, should hemodialysis become necessary in the future. A VA team approach for a permanent dialysis access can distinctly increase AVF use in children with a dramatic decrease in infection related complications and hospitalizations.32 The BOL VA team has two major goals: (1) establish a functional and safe autogenous access in each patient and (2) disseminate AVF surgical skills, techniques, and options to access surgeons at each location, in addition to providing didactic educational sessions for surgeons, nephrologists, nurses, and dialysis caregivers. Formal classroom presentations were given during the missions for topics such as preoperative and postoperative access evaluation, recognition of complications, care of dysfunctional fistulas, and best cannulation practices. Both clinical instruction and didactic presentation were used for ultrasound skills and vessel mapping, knowledge of all AVF options, and realistic options for local intervention for the surgeons. A BOL team of experienced cannulators returned to Guatemala after the first mission to help with the initial AVF cannulations. The Guatemalan pediatric surgeons have advanced from learning and assisting to the role of primary surgeon, with demonstrated skill in ultrasound, diagnosis, evaluation of all options, and surgical VA technique. BOL didactic sessions for nephrologists, surgeons, nurses, and dialysis technicians emphasized the importance of vein preservation. Although we have not collected data to measure this effort, we feel the impact has been successful. In addition, BOL facilitated donation of an ultrasound unit (FugiFilm-SonoSite Europe) for the pediatric surgical and nephrology departments, making an important advance in patient care. Two simple but critical examples in VA care improvement are that all dialysis catheters are now placed by an ultrasound-directed internal jugular approach and new patients and those with AVF dysfunction are now evaluated with vessel mapping. BOL is funded entirely by donations, both individual and cooperate. Physicians and other volunteers working
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with the missions raise funds or donate to support the cost of participation. BOL is an independent nonprofit 501(c)(3) public charity, improving health care in underserved areas around the world. Since 2006, BOL has completed more than 150 international medical missions and 300 domestic screenings in 26 countries. BOL surgeons are selected for their particular interest and experience in providing autogenous VA. Approximately 600 AVFs have been created for adults and children in seven locations serving Jamaica and Guatemala. Surgeons involved in the pediatric missions have a particular interest in creating AVFs in children.
CONCLUSIONS BOL surgical VA missions involve not only creating safe and functional AVFs, but also focus on working with local surgeons, nephrologists, and dialysis nurses to establish long-term collegial relationships. This study analyzes a series of pediatric VA missions to Guatemala. Three missions included 54 new patient consultations and access operations with cumulative AVF patency of 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. We wish to acknowledge the important work of Sara Hendren, Senior BOL Program Director, BA, MA(DevPrac), and the BOL organization, Lavonna Sanders, CRNA, Don Wood, CRNA, and Angie Aguilar, MD, for their important work in the care of these children. In addition, the following organizations generously contributed materials and equipment for these BOL missions: DaVita, Denver, Colorado; Ethicon, Somerville, New Jersey; FugiFilmSonoSite Europe, Amsterdam, The Netherlands; SonoSite USA, Bothell, Wash; Teratech, Burlington, Mass; W. L. Gore, Newark, Del; Avenu Medical, San Juan Capistrano, Calif; and Edwards Life Sciences, Irvine, Calif.
AUTHOR CONTRIBUTIONS Conception and design: WJ, RM, AM Analysis and interpretation: WJ, RM, NM, AM, SS, RT, JL, WG Data collection: WJ, RM, SS, RT Writing the article: WJ, AM Critical revision of the article: WJ, RM, NM, AM, SS, RT, JL, WG Final approval of the article: WJ, RM, NM, AM, SS, RT, JL, WG Statistical analysis: WJ, NM Obtained funding: Not applicable Overall responsibility: WJ
REFERENCES 1. Lou-Meda R. Comprehensive approach to pediatric kidney diseases in Guatemala. Clin Nephrol 2015;83(7 Suppl 1):82-4. 2. Bridge of Life. Overview of healthcare needs/. Available at: www. bridgeoflifeinternational.org/country/guatemala/. Accessed August 1, 2018.
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3. Jennings WC, Parker DE. Creating arteriovenous fistulas using surgeon-performed ultrasound. J Vasc Access 2016;17: 333-9. 4. Jennings WC, Kindred MG, Broughan TA. Creating radiocephalic arteriovenous fistulas: technical and functional success. J Am Coll Surg 2009;208:419-25. 5. Jennings WC, Mallios A, Blebea J. Upper extremity permanent hemodialysis access placement. In: Darling RC, Ozaki CK, editors. Master techniques in surgery: vascular surgery: hybrid, venous, dialysis access, thoracic outlet, and lower extremity procedures. Philadelphia: Wolters Kluwer; 2015. p. 151-63. 6. Jennings WC, Turman MA, Taubman KE. Arteriovenous fistulas for hemodialysis access in children and adolescents using the proximal radial artery inflow site. J Pediatr Surg 2009;44:1377-81. 7. Jennings WC, Mallios A, Mushtaq N. Proximal radial artery arteriovenous fistula for hemodialysis access. J Vasc Surg 2018;6:244-53. 8. Gradman WS, Laub J, Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia. J Vasc Surg 2005;41:279-84. 9. Wixon CL, Hughes JD, Mills JL. Understanding strategies for the treatment of ischemic steal syndromes after hemodialysis access. J Am Coll Surg 2000;191:301-10. 10. Arroyo MR, Sideman MJ, Spergel L, Jennings WC. Primary and staged transposition arteriovenous fistulas using the basilic and brachial veins. J Vasc Surg 2008;47:1279-83. 11. Kfoury E, Demaree CJ, Poi MJ, Matos JM, Bechara CF, Lin PH. Long-term outcomes of staged basilic vein transposition for hemodialysis access in children. J Vasc Access 2017;18: 366-70. 12. Almási-Sperling V, Galiano M, Lang W, Rother U, Rascher W, Regus S. Timing of first arteriovenous fistula cannulation in children on hemodialysis. Pediatr Nephrol 2016;31:1647-57. 13. Regus S, Almási-Sperling V, Lang W. Pediatric patients undergoing arteriovenous fistula surgery without intraoperative heparin. J Vasc Access 2016;17:494-8. 14. Lewis CG, Jennings WE. Avoidance of prophylactic antibiotics in creation of native arteriovenous fistulas. Dial Transplant 2003;32:308. 15. Gkotsis G, Jennings WC, Malik J, Mallios A, Taubman K. Treatment of high flow arteriovenous fistulas after successful renal transplant using a simple precision banding technique. Ann Vas Surg 2016;31:85-90. 16. Voorzaat BM, Janmaat CJ, Wilschut ED, Van Der Bogt KEA, Dekker FW, Rotmans JI. No consensus on physicians’ preferences on vascular access management after kidney transplantation: results of a multi-national survey. J Vasc Access 2018;20:52-9. 17. Lou-Meda R. ESRD in Guatemala and a model for preventive strategies: outlook of the Guatemalan Foundation for Children with Kidney Diseases. In: Renal failure. Abingdon, UK: Taylor & Francis; 2006;28. p. 689-91.
18. Cerón A, Fort MP, Morine CM, Lou-Meda R. Chronic kidney disease among children in Guatemala. Rev Panam Salud Publica 2014;36:376-82. 19. Harambat J, Stralen KJ, Kim J, Tizard JE. Epidemiology of chronic kidney disease in children. Pediatr Nephrol 2012;27: 363-73. 20. Clinical practice recommendation 8: vascular access in pediatric patients. Am J Kidney Dis 2006;48(Suppl 1):S274-6. 21. Jennings W, Blebea J. The optimal initial choice for permanent arteriovenous hemodialysis access. Position: excellent long-term outcomes for autogenous arteriovenous access justify an autogenous approach for most patients. J Vasc Surg 2013;58:539-48. 22. Vassalotti JA, Jennings WC, Beathard GA, Neumann M, Caponi S, Fox CH, et al. Fistula First Breakthrough Initiative Community Education Committee (2012). Fistula First Breakthrough Initiative: targeting catheter last in fistula first. Semin Dial 2012;25:303-10. 23. Baracco R, Mattoo T, Jain A, Kapur G, Valentini RP. Reducing central venous catheters in chronic hemodialysis–a commitment to arteriovenous fistula creation in children. Pediatr Nephrol 2014;29:2013-20. 24. Wartman SM, Rosen D, Woo K, Gradman WS, Weaver FA, Rowe V. Outcomes with arteriovenous fistulas in a pediatric population. J Vasc Surg 2014;60:170-4. 25. Kidney Disease Statistics for the United States. Data from the United States Renal Data Service 2015 Annual Data Report. Available at: www.niddk.nih.gov/health-information/ health-statistics/Pages/kidney-disease-statistics-united-states. aspx. Accessed April 8, 2019. 26. Schaefer F, Warady BA. Peritoneal dialysis in children with end-stage renal disease. Nat Rev Nephrol 2011;7:659-68. 27. Patal MC. Pediatric peritoneal dialysis: experience in Guatemala. J Nephrol Ther 2014;4:4. 28. Zaritsky JJ, Salusky IB, Gales B, Ramos G, Atkinson J, Allsteadt A, et al. Vascular access complications in long-term pediatric haemodialysis patients. Pediatr Nephrol 2008;23: 2061-5. 29. Bourquelot P. Vascular access in children: the importance of microsurgery for creation of autogenous arteriovenous fistulae. J Vasc Endovasc Surg 2006;32:696-700. 30. Akturk A, Bakx R, Oosterveld MJS, Wilde JCH, Idu MM. Microsurgery for “wrist” arteriovenous fistula creation in children: a retrospective cohort study. J Vasc Access 2018;19: 137-40. 31. Kim SM, Min SK, Ahn S, Min SI, Ha J. Outcomes of arteriovenous fistula for hemodialysis in pediatric and adolescent patients. Vasc Specialist Int 2016;32:113-8. 32. Baracco R, Mattoo T, Jain A, Kapur G, Valentini RP. Reducing central venous catheters in chronic hemodialysis–a commitment to arteriovenous fistula creation in children. Pediatr Nephrol 2014;29:2013-20.
Submitted Nov 4, 2018; accepted Feb 5, 2019.
ABSTRACT Objective: The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. Methods: Three surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions. Results: AVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 6 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 6 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 6 2.9 kg/m2). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications. Conclusions: Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months. (J Vasc Surg 2019;-:1-7.) Keywords: Arteriovenous fistula; Children; Pediatric; Hemodialysis; Vascular access; Medical mission
The Guatemalan Foundation for Children with Kidney Diseases (FUNDANIER) was established in 2003 by pediatric nephrologist Randall Lou-Meda, MD, as the first and only comprehensive pediatric nephrology program and
From the Department of Surgery, The University of Oklahoma, College of Medicine, Tulsaa; the Servicio de Nefrología, Hipertensión, Diálisis y Trasplante, Departamento de Pediatría, Hospital Roosevelt/FUNDANIER, Guatemala Cityb; the Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Tulsac; the Vascular Surgery Department, Institut Mutualiste Montsouris, Parisd; the Department of Pediatric Surgery, Roosevelt Hospital, Mariano Galvez University, Guatemala Citye; the Department of Surgery, Greenwood Leflore Hospital, Greenwoodf; and Private Practice, Beverly Hills.g Author conflict of interest: none. Correspondence: William C. Jennings, MD, Department of Surgery, The University of Oklahoma, College of Medicine, Tulsa, 1919 S Wheeling, Ste 600, Tulsa, OK 74104-2512 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.02.022
hemodialysis unit for children in Guatemala.1 Bridge of Life (BOL) is a not-for-profit charitable organization with expertise in chronic kidney disease (CKD) and was instrumental in supplying equipment, support, training, and expertise during formation and later maintenance of the hemodialysis unit.2 Cuffed dialysis catheters were not generally available at that time; therefore, noncuffed, nontunneled catheters provided almost all vascular access (VA). In addition, catheters were placed without ultrasound guidance due to limited access to ultrasound units and ultrasound catheter insertion training, resulting in many subclavian vein access sites used instead of the more desirable internal jugular vein approach. As the pediatric dialysis unit became firmly established, FUNDANIER requested BOL assistance in establishing a VA surgical program. BOL responded by leading their established team of experienced VA surgeons to create safe and functional arteriovenous fistulas (AVF) in these children. The BOL surgical AVF missions provide a full range of VA options, working with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships, fostering continued 1
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interaction, consultations, and return visits. This study analyzes the initial experience of the BOL pediatric VA missions to Guatemala.
ARTICLE HIGHLIGHTS d
d
METHODS The medical records of all patients who underwent a VA operation in Guatemala by the BOL surgical team were reviewed retrospectively. Preoperative evaluations were carried out by the BOL surgeons in conjunction with the Guatemalan pediatric nephrology and pediatric surgical teams. After physical examination, each patient underwent an ultrasound examination with vessel mapping by the BOL surgeons.3 An outflow vein diameter of 2.0 mm or greater was acceptable if the ultrasound examination showed a normal, compliant conduit without evidence of thickening or stenosis. Similarly, arterial inflow was deemed adequate when the intraluminal vessel diameter was 1.5 mm or greater. Other modes of ultrasound evaluation such as duplex imaging were used when clinically helpful. A radiocephalic AVF (RC-AVF) at the wrist was the first choice when possible.4,5 The RC-AVF configuration was selected by anatomical considerations with a side-to-side anastomosis when feasible, closing the distal outflow after completion. Mobilization of the radial artery while leaving the cephalic vein largely undisturbed was also favored when possible. Sutures used included Gore CV8 (W. L. Gore, Newark, Del) and polypropylene 7-0 and 6-0. Interrupted sutures were often used at the proximal portion of the anastomosis in smaller vessels. The second choice was generally a proximal radial artery (PRA) inflow fistula and a brachial artery inflow AVF was created when a distal anastomosis was not feasible.6,7 A femoral vein access was used when no upper extremity access was possible by clinical evaluation, such as a history of multiple bilateral subclavian vein catheters and failed further attempts at catheter placement, now with a femoral catheter, arm or face swelling after multiple subclavian catheters, or a failed previous AVF with arm swelling.8 When creating a brachial or femoral artery inflow AVF, care was taken to limit the size of the anastomosis in relation to the artery diameter.3,9 A primary AVF transposition was performed when direct AVF options were not available.8,10 AVFs that would necessitate a later staged transposition or other staged procedure were avoided in this setting. BOL surgeons were cognizant of the need to establish a safe AVF that would be expected to mature without intervention. Balloon angioplasty for maturation would not be available and surgical intervention for pediatric VA patients was in the process of being established with the Guatemalan surgical team with the option of staged transpositions expected for future missions.11 An individual Guatemalan pediatric surgeon with interest in VA (R.S.) was fully involved and participated in each mission, in addition to spending additional time and training with one of the BOL surgeons (A.M.) at
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d
Type of Research: Retrospective cohort study Key Findings: Pediatric vascular access missions to Guatemala treated 54 new patients, with primary and cumulative arteriovenous fistula (AVF) patencies of 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. AVF surgical and ultrasound skills, techniques, and options were exchanged with pediatric surgeons in addition to educational sessions for other physicians, nurses, and dialysis caregivers. Take Home Message: These pediatric surgical vascular access missions created safe and functional AVFs while working in a collaborative and teaching environment with local pediatric surgeons, nephrologists, and dialysis nurses, establishing long-term collegial relationships.
his institution. During subsequent missions, three additional surgeons from the group practice of fellowshiptrained pediatric surgeons have participated. The AVFs in this report were constructed during the BOL missions. The Guatemalan surgical team progressed during this time period from learning and assisting in surgery to undertaking primary and independent surgical procedures. The timing for initial cannulation was reviewed with the pediatric nephrology and dialysis teams and a 4- to 6-week period of observation was planned for AVF maturation.12 The operations were performed at the University of San Carlos School of Medicine associated Roosevelt Hospital in Guatemala City. Anesthesia was generally provided by laryngeal mask supplemented with local anesthetic; endotracheal intubation was avoided in most cases. Sedation with local anesthetic was appropriate for some patients. Prophylactic antibiotics and systemic heparin were not used routinely.13,14 Loupe visual magnification (3.3 5.0) was used during the operations. Patient follow-up was obtained through the pediatric nephrology and pediatric surgical attending physicians, fellows, and dialysis staff. Primary AVF patency was defined as the time (months) of uninterrupted patency and without intervention. Cumulative (secondary) patency was the period from the original AVF construction, regardless of interventions or thrombosis until completion of the study period, abandonment of the access, loss to follow-up, or death. A nonfunctional AVF was considered a failed access in the analysis. All operations were performed in association with the Guatemalan pediatric surgical attending physicians, fellows, and surgical residents. Each mission involved an exchange of surgical knowledge and teaching before, during, and after the procedures. In addition, didactic sessions and cannulation training for physicians,
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Table. Characteristics of the study participants and their association with primary and cumulative patency (n ¼ 54) Patency HR (95% CI) Variable
No. (%)
Primary
Cumulative
Age
13.35 6 2.83
0.94 (0.78-1.13)
1.03 (0.80-1.32)
Height (cm)a
131.21 6 12.42
0.98 (0.93-1.02)
0.99 (0.94-1.05)
Weight (kg)a
30.78 6 8.32
0.96 (0.90-1.02)
0.98 (0.90-1.07)
17.95 6 2.85
0.98 (0.82-1.17)
1.03 (0.81-1.31)
Female
25 (46.30)
1.15 (0.41-3.21)
0.36 (0.07-1.78)
Male
29 (53.70)
Reference
a
a
BMI
Gender Reference
Cause of renal failure Undetermined
38 (70.37)
Reference
Reference
Uropathy
13 (24.07)
2.58 (0.91-7.30)
3.20 (0.80-12.80)
Hypoplasia
2 (3.70)
e
e
IGA nephropathy
1 (1.85)
e
e
Dialysis catheters 0 1-2
4 (7.41)
e
e
17 (31.48)
Reference
Reference
3-4
17 (31.48)
1.68 (0.40-7.05)
1.54 (0.26-9.21)
$5
16 (29.63)
2.75 (0.71-10.65)
1.73 (0.29-10.39)
Operation Radiocephalic
21 (38.89)
Reference
Reference
Proxradial
12 (22.22)
0.44 (0.05-4.28)
1.77 (0.11-28.34)
5 (9.26)
3.50 (0.58-21.17)
4.06 (0.25-64.92)
16 (29.63)
4.04 (1.09-15.02)
7.29 (0.85-62.45)
Brachial Transposition
BMI, Body mass index; CI, confidence interval; HR, hazard ratio. Blank spaces indicate too few patients for analysis. a For age, height, weight, and body mass index, mean 6 standard deviations are reported as descriptive statistics.
nurses, and other care providers were provided separately. A life-table analysis was performed to obtain KaplanMeier plots and to evaluate overall patency rates at different time points. Univariate and multivariable association between primary patency and cumulative AVF patency rates and patient demographic variables were examined by Cox proportional hazards models. Hazard ratio (HR) and 95% confidence intervals (CIs) were calculated. Data were analyzed with SAS version 9.4 software (SAS Institute, Cary, NC), and significance of differences was set at P < .05. This study was approved by the ad hoc research ethics committee at FUNDANIER. Informed consent was not required.
RESULTS Three surgical pediatric VA missions were conducted in Guatemala with plans for continued assistance in the future. Each mission was approximately 1 week. The initial series of children were cared for in September 2015, the second group in November 2016, and the third group in December 2017. These missions were of equivalent durations and had similar patient numbers and characteristics. A total of 54 consecutive new pediatric
patients had a VA created, all were autogenous AVFs. The patient ages were 8 to 19 years (13.4 6 2.8 years) and 29 (54%) were male. Patient weights were 28 to 50 kg (30.8 6 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 6 2.9 kg/m2). The Table shows the characteristics of the study participants and their association with primary and cumulative patency. Radiocephalic AVFs were created in 21 children (39%); three of these were mid-forearm fistulas. AVFs were established using the PRA in 12 patients (22%) and the brachial artery in 5(9%). Bidirectional PRA-AVF flow was established in three patients. Sixteen patients required a transposition (30%). Twelve transpositions used the basilic vein in the arm and two in the forearm, all completed as a singlestage procedure. The femoral vein was used for a transposition in the thigh in one patient and harvested for translocation in a second individual. Only four patients had not required a previous dialysis catheter, whereas 23 children (43%) had a history of three or more catheters. The majority of catheters were placed through the subclavian vein. Eight AVFs failed during the study period (range, 1-9 months). Four of these children with a failed new AVF had a later access created including one graft. Two of these were successful, although all were
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Fig. Kaplan-Meier vascular access (VA) patency curves show primary and cumulative (secondary) patency during the study period. The number of patients at risk, patency rates, and standard errors are shown.
considered as failed in the study patency calculation. Primary patency and cumulative patency were 83% and 85% at 12 months, 68% and 85% at 24 months, and 62% and 85% at 36 months, respectively (Fig). The median follow-up was 17 months (range, 1-36 months). Cox regression analysis found that several preoperative characteristics influenced AVF primary and cumulative patency. Patients with a history of five or more dialysis catheters had a lower primary and cumulative patency compared with those children with one or two catheters (HR, 2.75 [95% CI, 0.71-10.65]; HR, 1.73 [95% CI, 0.29-10.39], respectively). The cause of renal failure was unknown for most individuals (70%); however, those patients with obstructive uropathy had worse primary and cumulative patency rates overall. Female children had higher cumulative patency than males (HR, 0.36; 95% CI, 0.36-1.78). Patient age, height, and weight did not influence patency rates. An analysis of operative procedures was performed by grouping inflow sites for direct AVFs as radiocephalic, PRA, and brachial artery while adding a fourth group for transposition procedures. PRA-AVFs demonstrated the highest primary patency (HR, 0.44; 95% CI, 0.05-4.28), whereas radiocephalic AVFs proved to have the best cumulative patency. The Table shows all preoperative factors as covariates in patency calculations.
There were no operative deaths or major complications. However, three patients were returned to the operating room by the BOL surgical team for access dysfunction. One patient required the evacuation of a hematoma, another underwent access thrombectomy, and a third AVF was revised due to low flow; all recovered without incident and maintained functioning AVFs. These operations were considered primary failures for patency calculations. Four patients required a later operation by the Guatemalan pediatric surgical team (R.S.), one for the successful repair of a venous outflow cannulation aneurysm and with two others undergoing revision for radiocephalic inflow stenosis. A fourth child with brachial artery inflow developed a high-output AVF and underwent successful banding for flow reduction. An additional patient with an upper arm AV graft created elsewhere in Guatemala had severe arm swelling with an eroding pseudoaneurysm and bilateral subclavian vein occlusions from past catheters. Retrograde flow into large forearm veins maintained the graft patency. The graft and aneurysm were resected. No access opportunities were present in the contralateral arm; therefore, a low-flow distal radiocephalic AVF was created in the ipsilateral arm using a matured vein and successful cannulation was possible the following day. However, arm swelling eventually returned, requiring AVF ligation.
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During the second BOL mission, a child with a primary basilic vein transposition created during the initial mission had a high-grade proximal swing-site outflow stenosis that was successfully bridged proximal to the cannulation zone with a short PTFE (Gore, Flagstaff, Ariz) graft segment. During the third mission two previous BOL patients underwent successful dysfunctional AVF repair with preservation of uninterrupted dialysis access. Each had an RC-AVF with poor inflow secondary to juxta-anastomotic stenosis. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage. Seven patients died during the study period owing to causes unrelated to AVF access and with functional fistulas. FUNDANIER established a pediatric renal transplantation program in 2007 and 88 patients have received a kidney transplant. Among the children with an AVF created by BOL surgeons, four have been successfully transplanted and remain well. The AVFs in these children are asymptomatic with moderate flow and have not been ligated.15,16 These AVFs are being followed and evaluated clinically.
DISCUSSION The population of the Republic of Guatemala is approximately 16 million people. It has been estimated that 400 children develop CKD annually in Guatemala associated with reflux nephropathy, chronic glomerulonephritis, or neurogenic bladder as the leading causes of CKD in these patients.17 Many individuals in rural areas of Guatemala lack access to specialized healthcare facilities with delays in referral for diagnosis and treatment of CKD and end-stage renal disease (ESRD), possibly resulting in an under-reporting of the true incidence and prevalence of kidney disease.18 The prevalence worldwide of childhood renal replacement therapy in 2008 was 18 to 100 per million.19 Although the most common causes of childhood ESRD in developed countries are congenital disorders, acquired illnesses are more common in developing countries. The survival rate of children with ESRD overall is roughly 30 times lower than that of healthy children.19 The National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines recommends a permanent VA for children when hemodialysis is anticipated for 1 year or longer and when peritoneal dialysis (PD) or kidney transplantation is not available.20 As in adults, when hemodialysis is necessary in children, an autogenous VA is widely recommended. AVFs are associated with lower mortality and serious morbidity such as infection, access failure, and hospitalizations.21,22 These complications are more likely with grafts and particularly more likely with central venous catheter dialysis access. The National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines and the Fistula First programs have been associated with a dramatic rise in successful autogenous
access creation.20,22 AVF prevalence in children has also increased substantially over the last 10 years, although pediatric hemodialysis in United States represents only 2% of the patients receiving dialysis therapy.6,23-25 A total of 1462 children in the United States began ESRD care in 2013 with 9921 children treated for ESRD at years end, compared with 468,000 adults undergoing treatment for ESRD.25 The most common initial ESRD treatment modality among children in the United States overall was hemodialysis (56%).25 PD is often the preferred dialysis modality for children in the United States when feasible, particularly in younger individuals. However, hemodialysis is increasingly selected for chronic dialysis and a majority of children requiring dialysis will need a permanent hemodialysis access. Causes of technical PD failure include repeated PD infections, previous abdominal surgery with adhesions, or a lack of adequate ultrafiltration for dialysis. Chronic PD in children may also be associated with hypertension and left ventricular hypertrophy from volume overload.26 A 2014 public health study of children in Guatemala with CKD found 175 patients receiving continuous ambulatory PD.27 However, accessibility and an acceptable environment for PD are not universally available in Guatemala. When hemodialysis is required, a permanent access allows children more normal activities and lifestyle, as opposed to central venous catheter dialysis. Establishing a functional AVF in children has been shown to be readily attainable in young patients and both procedures and cannulation aspects are well-tolerated.6,23,24,28 The median age of the children in this study was 13 years; however, the children’s size was quite small as evidenced by the mean height of 131 cm and mean weight of 30.8 kg. Although vessel sizes were not recorded in our database, veins 2 mm or larger and arteries 1.5 mm or greater in diameter were used successfully to create functional AVFs. Bourquelot et al29 has reported an extensive experience and successful AVF outcomes with use of an operative microscope in children, while other authors access outcomes with an operating microscope for VA have been more modest.30 Our practice has been to use loupe magnification of 3.3 to 5.0 times.6,23,24,31 Percutaneous intervention with balloon angioplasty for access salvage and maturation is readily available in the United States and Europe and may have resulted in higher cumulative patency for the AVF patients in this study, but was not an option for the pediatric dialysis patients during the study period. Recently, the Guatemalan pediatric surgeons have engaged the pediatric cardiologist Guatemalan Cardiovascular Unit to aid with percutaneous intervention and advanced imaging options for future pediatric dialysis patients. Similarly, staged basilic vein transposition procedures were not used in these initial patients, but we expect this option to be available in the future.11
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In the United States, children undergo renal transplantation sooner than adults and a 6- to 12-month period of catheter dialysis may be appropriate. Pediatric renal transplantation in Guatemala through FUNDANIER is becoming more common and, although the program is relatively new, has shown very promising results. Almost all pediatric transplanted kidneys in Guatemala are currently from living-related donations and the limitation on organ availability may influence the decision of when to establish a permanent dialysis access. Regardless of the decision concerning timing of a new access, ultrasound vessel mapping to determine the best site for a VA should be performed and the patient and family educated to protect the recommended venous outflow site from cannulation and intravenous infusion. Even when PD is selected, we recommend vessel mapping for all patients to identify and preserve the most favorable AVF site, should hemodialysis become necessary in the future. A VA team approach for a permanent dialysis access can distinctly increase AVF use in children with a dramatic decrease in infection related complications and hospitalizations.32 The BOL VA team has two major goals: (1) establish a functional and safe autogenous access in each patient and (2) disseminate AVF surgical skills, techniques, and options to access surgeons at each location, in addition to providing didactic educational sessions for surgeons, nephrologists, nurses, and dialysis caregivers. Formal classroom presentations were given during the missions for topics such as preoperative and postoperative access evaluation, recognition of complications, care of dysfunctional fistulas, and best cannulation practices. Both clinical instruction and didactic presentation were used for ultrasound skills and vessel mapping, knowledge of all AVF options, and realistic options for local intervention for the surgeons. A BOL team of experienced cannulators returned to Guatemala after the first mission to help with the initial AVF cannulations. The Guatemalan pediatric surgeons have advanced from learning and assisting to the role of primary surgeon, with demonstrated skill in ultrasound, diagnosis, evaluation of all options, and surgical VA technique. BOL didactic sessions for nephrologists, surgeons, nurses, and dialysis technicians emphasized the importance of vein preservation. Although we have not collected data to measure this effort, we feel the impact has been successful. In addition, BOL facilitated donation of an ultrasound unit (FugiFilm-SonoSite Europe) for the pediatric surgical and nephrology departments, making an important advance in patient care. Two simple but critical examples in VA care improvement are that all dialysis catheters are now placed by an ultrasound-directed internal jugular approach and new patients and those with AVF dysfunction are now evaluated with vessel mapping. BOL is funded entirely by donations, both individual and cooperate. Physicians and other volunteers working
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with the missions raise funds or donate to support the cost of participation. BOL is an independent nonprofit 501(c)(3) public charity, improving health care in underserved areas around the world. Since 2006, BOL has completed more than 150 international medical missions and 300 domestic screenings in 26 countries. BOL surgeons are selected for their particular interest and experience in providing autogenous VA. Approximately 600 AVFs have been created for adults and children in seven locations serving Jamaica and Guatemala. Surgeons involved in the pediatric missions have a particular interest in creating AVFs in children.
CONCLUSIONS BOL surgical VA missions involve not only creating safe and functional AVFs, but also focus on working with local surgeons, nephrologists, and dialysis nurses to establish long-term collegial relationships. This study analyzes a series of pediatric VA missions to Guatemala. Three missions included 54 new patient consultations and access operations with cumulative AVF patency of 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. We wish to acknowledge the important work of Sara Hendren, Senior BOL Program Director, BA, MA(DevPrac), and the BOL organization, Lavonna Sanders, CRNA, Don Wood, CRNA, and Angie Aguilar, MD, for their important work in the care of these children. In addition, the following organizations generously contributed materials and equipment for these BOL missions: DaVita, Denver, Colorado; Ethicon, Somerville, New Jersey; FugiFilmSonoSite Europe, Amsterdam, The Netherlands; SonoSite USA, Bothell, Wash; Teratech, Burlington, Mass; W. L. Gore, Newark, Del; Avenu Medical, San Juan Capistrano, Calif; and Edwards Life Sciences, Irvine, Calif.
AUTHOR CONTRIBUTIONS Conception and design: WJ, RM, AM Analysis and interpretation: WJ, RM, NM, AM, SS, RT, JL, WG Data collection: WJ, RM, SS, RT Writing the article: WJ, AM Critical revision of the article: WJ, RM, NM, AM, SS, RT, JL, WG Final approval of the article: WJ, RM, NM, AM, SS, RT, JL, WG Statistical analysis: WJ, NM Obtained funding: Not applicable Overall responsibility: WJ
REFERENCES 1. Lou-Meda R. Comprehensive approach to pediatric kidney diseases in Guatemala. Clin Nephrol 2015;83(7 Suppl 1):82-4. 2. Bridge of Life. Overview of healthcare needs/. Available at: www. bridgeoflifeinternational.org/country/guatemala/. Accessed August 1, 2018.
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3. Jennings WC, Parker DE. Creating arteriovenous fistulas using surgeon-performed ultrasound. J Vasc Access 2016;17: 333-9. 4. Jennings WC, Kindred MG, Broughan TA. Creating radiocephalic arteriovenous fistulas: technical and functional success. J Am Coll Surg 2009;208:419-25. 5. Jennings WC, Mallios A, Blebea J. Upper extremity permanent hemodialysis access placement. In: Darling RC, Ozaki CK, editors. Master techniques in surgery: vascular surgery: hybrid, venous, dialysis access, thoracic outlet, and lower extremity procedures. Philadelphia: Wolters Kluwer; 2015. p. 151-63. 6. Jennings WC, Turman MA, Taubman KE. Arteriovenous fistulas for hemodialysis access in children and adolescents using the proximal radial artery inflow site. J Pediatr Surg 2009;44:1377-81. 7. Jennings WC, Mallios A, Mushtaq N. Proximal radial artery arteriovenous fistula for hemodialysis access. J Vasc Surg 2018;6:244-53. 8. Gradman WS, Laub J, Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia. J Vasc Surg 2005;41:279-84. 9. Wixon CL, Hughes JD, Mills JL. Understanding strategies for the treatment of ischemic steal syndromes after hemodialysis access. J Am Coll Surg 2000;191:301-10. 10. Arroyo MR, Sideman MJ, Spergel L, Jennings WC. Primary and staged transposition arteriovenous fistulas using the basilic and brachial veins. J Vasc Surg 2008;47:1279-83. 11. Kfoury E, Demaree CJ, Poi MJ, Matos JM, Bechara CF, Lin PH. Long-term outcomes of staged basilic vein transposition for hemodialysis access in children. J Vasc Access 2017;18: 366-70. 12. Almási-Sperling V, Galiano M, Lang W, Rother U, Rascher W, Regus S. Timing of first arteriovenous fistula cannulation in children on hemodialysis. Pediatr Nephrol 2016;31:1647-57. 13. Regus S, Almási-Sperling V, Lang W. Pediatric patients undergoing arteriovenous fistula surgery without intraoperative heparin. J Vasc Access 2016;17:494-8. 14. Lewis CG, Jennings WE. Avoidance of prophylactic antibiotics in creation of native arteriovenous fistulas. Dial Transplant 2003;32:308. 15. Gkotsis G, Jennings WC, Malik J, Mallios A, Taubman K. Treatment of high flow arteriovenous fistulas after successful renal transplant using a simple precision banding technique. Ann Vas Surg 2016;31:85-90. 16. Voorzaat BM, Janmaat CJ, Wilschut ED, Van Der Bogt KEA, Dekker FW, Rotmans JI. No consensus on physicians’ preferences on vascular access management after kidney transplantation: results of a multi-national survey. J Vasc Access 2018;20:52-9. 17. Lou-Meda R. ESRD in Guatemala and a model for preventive strategies: outlook of the Guatemalan Foundation for Children with Kidney Diseases. In: Renal failure. Abingdon, UK: Taylor & Francis; 2006;28. p. 689-91.
18. Cerón A, Fort MP, Morine CM, Lou-Meda R. Chronic kidney disease among children in Guatemala. Rev Panam Salud Publica 2014;36:376-82. 19. Harambat J, Stralen KJ, Kim J, Tizard JE. Epidemiology of chronic kidney disease in children. Pediatr Nephrol 2012;27: 363-73. 20. Clinical practice recommendation 8: vascular access in pediatric patients. Am J Kidney Dis 2006;48(Suppl 1):S274-6. 21. Jennings W, Blebea J. The optimal initial choice for permanent arteriovenous hemodialysis access. Position: excellent long-term outcomes for autogenous arteriovenous access justify an autogenous approach for most patients. J Vasc Surg 2013;58:539-48. 22. Vassalotti JA, Jennings WC, Beathard GA, Neumann M, Caponi S, Fox CH, et al. Fistula First Breakthrough Initiative Community Education Committee (2012). Fistula First Breakthrough Initiative: targeting catheter last in fistula first. Semin Dial 2012;25:303-10. 23. Baracco R, Mattoo T, Jain A, Kapur G, Valentini RP. Reducing central venous catheters in chronic hemodialysis–a commitment to arteriovenous fistula creation in children. Pediatr Nephrol 2014;29:2013-20. 24. Wartman SM, Rosen D, Woo K, Gradman WS, Weaver FA, Rowe V. Outcomes with arteriovenous fistulas in a pediatric population. J Vasc Surg 2014;60:170-4. 25. Kidney Disease Statistics for the United States. Data from the United States Renal Data Service 2015 Annual Data Report. Available at: www.niddk.nih.gov/health-information/ health-statistics/Pages/kidney-disease-statistics-united-states. aspx. Accessed April 8, 2019. 26. Schaefer F, Warady BA. Peritoneal dialysis in children with end-stage renal disease. Nat Rev Nephrol 2011;7:659-68. 27. Patal MC. Pediatric peritoneal dialysis: experience in Guatemala. J Nephrol Ther 2014;4:4. 28. Zaritsky JJ, Salusky IB, Gales B, Ramos G, Atkinson J, Allsteadt A, et al. Vascular access complications in long-term pediatric haemodialysis patients. Pediatr Nephrol 2008;23: 2061-5. 29. Bourquelot P. Vascular access in children: the importance of microsurgery for creation of autogenous arteriovenous fistulae. J Vasc Endovasc Surg 2006;32:696-700. 30. Akturk A, Bakx R, Oosterveld MJS, Wilde JCH, Idu MM. Microsurgery for “wrist” arteriovenous fistula creation in children: a retrospective cohort study. J Vasc Access 2018;19: 137-40. 31. Kim SM, Min SK, Ahn S, Min SI, Ha J. Outcomes of arteriovenous fistula for hemodialysis in pediatric and adolescent patients. Vasc Specialist Int 2016;32:113-8. 32. Baracco R, Mattoo T, Jain A, Kapur G, Valentini RP. Reducing central venous catheters in chronic hemodialysis–a commitment to arteriovenous fistula creation in children. Pediatr Nephrol 2014;29:2013-20.
Submitted Nov 4, 2018; accepted Feb 5, 2019.