الفهرس 
Renal Failure in ChildrenOnly 14 pages are availabe for public view
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Abstract
Recent data indicate that the incidence of end-stage renal disease in pediatric patients (age 0-19) has increased over the past two decades. Often renal failure is only one aspect of a generalized disease or multiple congenital anomalies. Once it becomes clear to the pediatric nephrologists that dialysis will soon be needed, a decision regarding the method of dialytic therapy will need to be made, and arrangements made for creating either vascular or peritoneal access (or both).
Choices in dialysis treatment for infants and children are wide and include the full range of therapies utilized in adult patients. Furthermore, there are indications for and complications of the dialysis procedure that are unique to children.
Despite the recent increase in the use of peritoneal dialysis to treat end-stage renal disease in children, hemodialysis continues to be a viable option in adolescents and older children. Although the technical problems associated with hemodialysis in young infants are considerable, this modality in some instances can be successfully used in the infants with end-stage renal disease, especially those awaiting transplantation. The use of chronically implanted venous catheters or the creation of arteriovenous fistulas in infants and young children has enabled pediatric nephrologists to successfully Hemodialyze even very young infants.
Ensuring efficient and effective dialysis relies on good access. This requires a dedicated, experienced and enthusiastic team. The access clinic allows for well planned surgery, good post-operative monitoring and aggressive screening in order to pick up early complications. This will result in improved patient dialysis, less frequent hospitalizations for access morbidity, reduced dialysis workload and overall healthcare costs.
The choice of vascular access is dependent primarily on the age and size of the patient, the duration for which the therapy is required and the flow rates that need to be achieved (refer to figure 1)
Available techniques of autogenous arteriovenous fistula formation have been discussed, and a rational strategy of successive hemodialysis access placement has been suggested. Whenever feasible, autogenous arteiovenous fistulae are preferred over prosthetic bridge grafts. A functional access is a lifeline for the dialysis pediatric patient, and it is the responsibility of the surgeon to create the best and most durable access possible.
Despite emerging vascular graft technologies, the basic autogenous arteriovenous fistula remains the first choice for chronic access for hemodialysis in children. Once autogenous options have been exhausted, prosthetic fistulae become the mainstay of maintenance hemodialysis access alternatives. Placement should begin in the nondominant upper extremity at the most distal site possible to achieve durable functioning. Grafts constructed of Expanded Polytetrafluorethylene provide the most consistent uninterrupted performance, have low rates of infectious and aneurysmal complications, and are easy to thrombectomize when thrombosis occurs.
As the dialysis pediatric population usually has other co-morbidities, the provision of a successful access will entail an ever increasing workload and it is inevitable that more complications will be seen. However, with the increasing use of thrombolysis, angioplasty and stent insertion, it is likely that treatment of complications will become an increasing workload for the radiologist rather than surgeon. It is important that all access procedures are well planned, well performed and well monitored for complications. When complications do occur, they need to be recognized and treated early, to preserve access if possible and to avoid irrecoverable damage to the limb.
Peritoneal dialysis via a Tenchkoff catheter is currently the primary method of dialysis in very small children. It is especially useful in children who are small and those who live far away from dialysis centers. Adolescent children also adapt well to this method of dialysis but do require constant supervision and careful management. Success depends on a collaborative home environment and the ability to be trained in sterile techniques. In addition to this, carers must be able to rapidly identify the complications and report them. The use of this method of dialysis has greatly reduced the need of vascular access for small children.