Vascular Access and Peritoneal Dialysis Catheter Placement in Children

Renal replacement therapy for children with end-stage renal disease consists of kidney transplantation or dialysis. Dialysis is often required at the outset of diagnosis due to urgent start need in many cases and inadequate organ supply in others. Both hemodialysis and peritoneal dialysis (PD) are relied upon as lifesaving modalities with the ultimate goal of reaching renal transplantation. Hemodialysis requires successful attainment of vascular access, which can be accomplished by placement of an arteriovenous fistula (AVF), arteriovenous graft (AVG), or central venous catheter (CVC). The pros and cons of each vascular access strategy are discussed, with the emphasis on avoiding CVCs due to morbidity of increased bloodstream infections, increased hospitalizations, need for frequent revisions, along with long-term complications such as central venous stenosis and thrombosis, which make placement of successful AVF or AVG more difficult. Strategies to increase AVF and AVG are discussed. PD is the most common modality for children 9 years old or younger. PD requires surgical placement of a PD catheter. Successful PD catheter placement begins with proper patient selection, followed by timely surgical consultation and preoperative patient preparation. Next, intraoperative approaches, including partial omentectomy and pelvic catheter location followed by postoperative tactics, are discussed with the focus on optimizing successful PD catheter placement with minimal complications. The hope is that the reader will gain a better understanding of strategies to secure an optimal dialysis access for the child requiring either hemodialysis or PD.