Introduction:
End-stage kidney disease is an important cause of mortality among children in low resource settings. The disease is uniformly fatal in the absence of renal replacement therapy. Access to chronic renal replacement therapy is limited in low resource settings and this is particularly so for children than adults due to challenges of sourcing for the appropriate paediatric consumables and limitation in number of centres with experts in providing such care.
In our setting, chronic peritoneal dialysis service is limited. The most common form of chronic renal replacement therapy among adults is haemodialysis and the most common access is the right jugular tunnelled vascular access. Other challenges in our setting includes lack of functional C-arm to assist with fluoroscopic guidance during tunnelled vascular device placement; hence, ultrasound alone is often used to guide placement after which position of catheter tip is confirmed on plain chest radiograph. Furthermore, the creation of central vascular access in children requires requires a form of sedation and analgesia as unlike in adults, children cannot tolerate painful invasive procedures such as the creation of tunnelled catheter access. .
The tunnelled central catheter placement is the most common route for maintenance haemodialysis among children in developed countries. Few reported cases are available from low resource settings such as ours. This study is a prospective observational report of paediatric patients who underwent tunnelled central catheter insertion for maintenance haemodialysis at the University College Hospital, Ibadan, Nigeria
Methods:
Analysis of a prospective database of children undergoing tunneled vascular access for haemodialysis in our hospital from August 2019 – August 2024. Written parental consent was obtained before procedure. All patients were reviewed by the anaesthesiologist before the procedure and also provided sedation during the procedure. The tunneled vascular access was carried out under ultrasound guidance. Size of the vascular catheter was based on recommendations for the weight of the patient. The procedure was done in anticipation of kidney transplantation and for children whose parents chose dialysis over conservative treatment for ESRD.
Results:
7 patients underwent 8 sessions of the tunneled central catheter insertion. They were aged 5-14 years (median 9 years). There were 4 females (57.1%) and 3 males. The causes of ESRD were posterior urethral valves in 2 patients, neurogenic bladder, focal segmental glomerulosclerosis with steroid resistant nephrotic syndrome, chronic glomerulonephritis, lupus nephritis, and sepsis with haemorrhagic pancreatitis in each of the other patients. Serum creatinine before the procedure was median 6.3 IQR 5.1-8.6mg/dl. Ketofol (ketamine plus propofol) was used as a form of analgosedation in 50% of patients.. The right internal jugular vein was cannulated in all cases, and cannulation was successful in 6 of the 8 sessions. The mean duration of venous cannulation was 37 (15-105) minutes while the mean duration of sedation was 48.88 (20-130) minutes. One patient (12.5%) had respiratory depression (RR ≤10) and one patient (12.5%) suffered a cardiac arrest during the procedure but was successfully resuscitated. Another patient who had bilateral lower limb hypoplasia with unsuccessful femoral venous cannulation, and who had pulled out a temporary internal jugular access, had a cardiopulmonary arrest about 1 hour into the procedure and died. One patient who also needed immediate dialysis bled transiently from the access site, however bleeding resolved spontaneously.
Conclusions:
The report showed a relatively high success rate in ultrasound-guided central venous cannulation in paediatric cohorts with end-stage kidney diseases in a low resource setting. Outcomes may be improved with support equipment such as C-arm, and increased access to paediatric-sized dialysis catheters. The study outcomes underscores need for services for prevention of ESRD and development of kidney transplant programmes in children.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.