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Author(s): Evgenia Preka [sup.1] , Rukshana Shroff [sup.2] , Lynsey Stronach [sup.2] , Francis Calder [sup.2] [sup.3] , Constantinos J. Stefanidis [sup.4] Author Affiliations: (1) grid.461841.e, Southampton Children's Hospital and [...], Arteriovenous fistulas (AVFs) are widely used for haemodialysis (HD) in adults with stage 5 chronic kidney disease (CKD 5) and are generally considered the best form of vascular access (VA). The 'Fistula First' initiative in 2003 helped to change the culture of VA in adults. However, this cultural change has not yet been adopted in children despite the fact that a functioning AVF is associated with lower complication rates and longer access survival than a central venous line (CVL). For children with CKD 5, especially when kidney failure starts early in life, there is a risk that all VA options will be exhausted. Therefore, it is essential to develop long-term strategies for optimal VA creation and maintenance. Whilst AVFs are the preferred VA in the paediatric population on chronic HD, they may not be suitable for every child. Recent guidelines and observational data in the paediatric CKD 5 population recommend switching from a 'Catheter First' to 'Catheter Last' approach. In this review, recent evidence is summarized in order to promote change in current practices.

Author(s): Martin Garcia-Nicoletti [sup.1] , Manish D. Sinha [sup.1] [sup.2] , Alexandra Savis [sup.3] , Shazia Adalat [sup.1] , Narayan Karunanithy [sup.4] [sup.5] , Francis Calder [sup.1] [sup.6] Author Affiliations: [...], Background Catheter-associated right atrial thrombus (CRAT) is a recognised complication of central venous catheter (CVC) use for haemodialysis (HD) patients. Methods This was a single-centre retrospective longitudinal observational study of consecutive children aged 6 months-18 years over a 7-year period receiving in-centre chronic HD. Echocardiograms as per routine cardiac surveillance were performed 6 months or earlier given clinical concerns. Results Sixty-five children, 36 boys (55.4%), median (IQR) age 11.8 (5.3, 14.7) years, received HD for kidney failure with replacement therapy (KFRT). Initial modality was HD in 45 (69.2%), with CVC as initial access in 42 (93.3%) and AVF in 3 (6.7%); in the remaining 20 (30.8%) patients PD was the initial modality before switching to HD. Seven of 65 (10.8%) developed CRAT at median 2 (0.8, 8.4) months from CVC insertion, with one CRAT detected 3 days following insertion. One child had 2 episodes of CRAT and one additionally thrombosed their AVF. No patient had an underlying primary kidney disease associated with a pro-thrombotic state. Those with CRAT were younger, had more frequent CVC change and received dialysis for longer duration compared to those with no CRAT. Six episodes of CRAT (75%) received anticoagulation therapy. Infective complications were observed in 25% and catheter malfunction in 50%. Five CRAT episodes (62.5%) resulted in CVC loss. One patient died after a haemorrhagic complication of anticoagulation and sepsis, and another developed life-threatening superior vena cava obstruction syndrome. Overall mortality 14% (1/7). Conclusions This is the first report of CRAT in a paediatric HD population. There was ~ 11% incidence of CRAT in patients receiving chronic HD detected by surveillance echocardiography. Although frequently asymptomatic, CRAT is associated with serious sequelae. Anticoagulation and surveillance with expert echocardiography remain mainstays of management. Graphical abstract

Author(s): Petrut Gogalniceanu [sup.1] [sup.2] [sup.3] , Sam Stuart [sup.2] , Narayan Karunanithy [sup.1] , Nicos Kessaris [sup.1] [sup.2] , Derek Roebuck [sup.2] , Francis Calder [sup.1] [sup.2] Author Affiliations: [...], Background Arteriovenous fistulae (AVF) provide superior primary vascular access for children on chronic dialysis compared to central venous catheters (CVC). However, AVFs inevitably develop complications and will require some intervention to maintain long-term functional patency. Methods We report an 'endovascular-first' approach to the maintenance and rescue of paediatric AVFs. Thirty interventions targeting 46 lesions in 18 children (median age 11 years [range 5-17]) were performed. Sixty-eight percent of the AVFs were brachio-cephalic fistulae, 26% brachio-basilic fistulae and 5% radio-cephalic fistulae. Immediate functional success was 86% with good dialysis adequacy (mean urea reduction ratio > 70%) at 3 months post procedure. Results There was one significant complication, consisting of an AVF rupture which was managed with a covered stent. Conclusions Repeated interventions may be necessary to maintain AVF patency and avoid central venous catheters. This is the largest series reported to date.

Author(s): Rukshana Shroff[sup.1] , Rosalie B Sterenborg[sup.1] , Adam Kuchta[sup.2] , Andrew Arnold[sup.2] , Nicholas Thomas[sup.2] , Lynsey Stronach[sup.1] , Soundrie Padayachee[sup.2] , Francis Calder[sup.1] [sup.2] Author Affiliations: (1) Great [...], Background Arteriovenous fistula (AVF) formation for long-term haemodialysis in children is a niche discipline with little data for guidance. We developed a dedicated Vascular Access Clinic that is run jointly by a transplant surgeon, paediatric nephrologist, dialysis nurse and a clinical vascular scientist specialised in vascular sonography for the assessment and surveillance of AVFs. We report the experience and 2-year outcomes of this clinic. Methods Twelve new AVFs were formed and 11 existing AVFs were followed up for 2 years. All children were assessed by clinical and ultrasound examination. Results During the study period 12 brachiocephalic, nine basilic vein transpositions and two radiocephalic AVFs were followed up. The median age (interquartile range) and weight of those children undergoing new AVF creation were 9.4 (interquartile 3-17) years and 26.9 (14-67) kg, respectively. Pre-operative ultrasound vascular mapping showed maximum median vein and artery diameters of 3.0 (2-5) and 2.7 (2.0-5.3) mm, respectively. Maturation scans 6 weeks after AVF formation showed a median flow of 1277 (432-2880) ml/min. Primary maturation rate was 83 % (10/12). Assisted maturation was 100 %, with two patients requiring a single angioplasty. For the 11 children with an existing AVF the maximum median vein diameter was 14.0 (8.0-26.0) mm, and the median flow rate was 1781 (800-2971) ml/min at a median of 153 weeks after AVF formation. Twenty-two AVFs were used successfully for dialysis, a median kt/V of 1.97 (1.8-2.9), and urea reduction ratio of 80.7 % (79.3-86 %) was observed. One child was transplanted before the AVF was used. Conclusions A multidisciplinary vascular clinic incorporating ultrasound assessment is key to maintaining young children on chronic haemodialysis via an AVF.

Introduction Most children with chronic kidney disease can expect that a successful renal transplant is an achievable goal and will provide the best survival and quality of life. Although significant [...], Background There are no guidelines for the removal of a failed renal allograft, and its impact on subsequent dialysis and retransplantation has not yet been described. Methods We performed a 10-year review of allograft failure to study the factors that determined an outcome of transplant nephrectomy and choice of subsequent renal replacement therapy in children with or without nephrectomy. Results A total of 34 children developed graft failure over the 10-year study period, of whom 18 (53 %) required transplant nephrectomy. The median graft survival was 1.1 (range 0.2-10.6) versus 7.5 (1.5-15.0) years in the nephrectomy and non-nephrectomy groups, respectively (p=0.011). Children with graft failure within 1 year of transplantation were four-fold more likely to require transplant nephrectomy than those with graft failure after 1 year (p=0.04). Renal biopsy performed at [less than or equal to] 8 weeks prior to graft loss showed Banff grade II acute rejection in 13 of the 18 children who required subsequent nephrectomy versus three of the 13 children who did not need nephrectomy (p=0.01). Inflammation (fever, graft tenderness and raised C-reactive protein (CRP) in the 2 weeks preceding graft failure) was seen in 66 % of nephrectomized children, but not in any in the non-nephrectomy group (p=0.0003 for CRP between groups). Banff II rejection, an inflammatory response and the time post-transplantation significantly and independently predicted the outcome of nephrectomy (p=0.008, [R.sup.2] = 67 %). Human leukocyte antigen (HLA) antibody levels after graft failure were higher in the nephrectomy group (p=0.0003), but there was no difference between groups in terms of the presence or class of donor-specific antibodies. Of the children with graft failure, 82 % required dialysis (61 % hemodialysis) and 35 % have to date been successfully retransplanted. Conclusions Children with Banff II rejection, an inflammatory response and early graft loss are more likely to require transplant nephrectomy. Nephrectomy may be associated with higher circulating HLA antibody levels. Keywords Renalallograft failure * Transplantnephrectomy * Children * Donor-specific antibodies * Humanleukocyte antigen antibodies

Introduction For adults with end-stage renal disease (ESRD) on hemodialysis, the principle of 'Fistula First' has been key to a change in attitude to vascular access for hemodialysis (HD) which [...], The principle of "Fistula First" for hemodialysis has been widely adopted among adults with end-stage renal failure (ESRF). UK national targets aim to have 85 % of prevalent patients using permanent access (arteriovenous fistula or graft). Currently, hemodialysis in children relies heavily on central venous catheters (CVC). However, there is significant evidence that arteriovenous fistulae (AVF) are preferable for long-term dialysis in the pediatric population. We describe the principles of fistula formation including preoperative work-up, surgical techniques for AVF creation, and post-operative monitoring. Keywords Pediatric hemodialysis * Arteriovenous fistula * Vascular access * Arteriovenous access

Introduction Arteriovenous fistula (AVF) is the recommended form of vascular access for chronic haemodialysis (HD) in adults [1]. A small number of studies with few patients have suggested that the [...], Background Despite the Fistula First initiative there is still reluctance to use arteriovenous fistulas (AVF) for chronic haemodialysis (HD) in children. Our aim was to compare outcomes of AVFs and central venous lines (CVL) in children on chronic HD in a centre where AVF is the primary choice for vascular access. Patients and methods This was a retrospective case notes analysis of access complications, dialysis adequacy and laboratory outcomes in children who underwent dialysis for at least a year by AVF (n=20, median age 14.2 years, range (2.9-16.5) and CVL (n=5, median age 2.4 years, range 2.0-12.2) between January 2007 and December 2010. Results Primary access failure rate (patient-months) was 1 per 78.8 for AVF (n=5) and 1 per 15.5 for CVLs (n=7, p=0.3). Failure thereafter was 1 per131.3 and 1 per18.5 for AVF and CVLs respectively (n=3 and 6 respectively; p=0.2). The annualised hospitalisation rate for access malfunction was 0.44% and 3.1% for AVFs and CVLs respectively (p=0.004). Patients with AVFs had a lower infection rate of 0.25 per 100 patient-months compared with CVL at 3.2 per 100 (p=0.002). There was no difference in dialysis adequacy or laboratory values between AVF and CVL groups. Access survival rates (including both primary and secondary access failure) were significantly higher for AVF compared with CVL (p=0.0002, hazard ratio=0.15, 95% confidence interval 0.04-0.37). Conclusions Patients with AVF spend less time in hospital than those dialysed by CVLs and have a much lower access infection rate. These findings emphasise the need to use AVF as first-line access for paediatric patients on chronic HD. Keywords Haemodialysis * Arteriovenous fistula * Central venous line

Background There are three principle forms of vascular access available for the treatment of children with end stage kidney disease (ESKD) by haemodialysis: tunnelled catheters placed in a central vein (central venous lines, CVLs), arteriovenous fistulas (AVF), and arteriovenous grafts (AVG) using prosthetic or biological material. Compared with the adult literature, there are few studies in children to provide evidence based guidelines for optimal vascular access type or its management and outcomes in children with ESKD. Methods The European Society for Paediatric Nephrology Dialysis Working Group (ESPN Dialysis WG) have developed recommendations for the choice of access type, pre-operative evaluation, monitoring, and prevention and management of complications of different access types in children with ESKD. Results For adults with ESKD on haemodialysis, the principle of "Fistula First" has been key to changing the attitude to vascular access for haemodialysis. However, data from multiple observational studies and the International Paediatric Haemodialysis Network registry suggest that CVLs are associated with a significantly higher rate of infections and access dysfunction, and need for access replacement. Despite this, AVFs are used in only ∼25% of children on haemodialysis. It is important to provide the right access for the right patient at the right time in their life-course of renal replacement therapy, with an emphasis on venous preservation at all times. While AVFs may not be suitable in the very young or those with an anticipated short dialysis course before transplantation, many paediatric studies have shown that AVFs are superior to CVLs. Conclusions Here we present clinical practice recommendations for AVFs and CVLs in children with ESKD. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system has been used to develop and GRADE the recommendations. In the absence of high quality evidence, the opinion of experts from the ESPN Dialysis WG is provided, but is clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to local expertise and individual patient needs as appropriate. [ABSTRACT FROM AUTHOR]