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Psychosocial Barriers to Permanent Hemodialysis Access in Pediatric Patients
Sarah M. Wartman, MD, Karen Woo, MD, S Grace Huang, MD, JungAh Franchesca Hwang, BS, Jeffrey Johnson, MD, Fred A. Weaver, MD, Vincent L. Rowe, MD.
University of Southern California, Los Angeles, CA, USA.
Background: Kidney Disease Outcome Quality Initiative recommends creation of permanent access in pediatric patients aged 0-19 over 20kg initiating hemodialysis (HD). Recent data, however, indicates that less than 20% of pediatric patients receive HD through arteriovenous fistulas (AVF) or grafts (AVG), and initiation of dialysis via central venous catheter (CVC) has increased to over 90% in recent years. The aim of this study is to determine if psychosocial factors impact the type of access chosen by pediatric patients.
Methods: An original survey was designed and administered to all pediatric HD patients and their parents at a single institution. Survey questions were specific to the type of access currently used by the patient for HD.
Results: Of the twenty-five surveys distributed, 23 patient and 10 parent surveys were received. Thirteen (57%) of the patients dialyzed via CVC and ten (43%) with an AVF. Mean age was 13 in the CVC group and 17 in the AVF group (P = .01). There was no statistical difference between CVC and AVF groups in perception of fistulas being "ugly" (54% vs. 60%), or having an aversion to being accessed with needles (54% vs. 60%). Of CVC patients, 46% were "afraid of what people would say/think" about their fistula appearance, while only 30% shared this feeling in the AVF group. In fact, 70% of patients in AVF group were satisfied with their access and only 20% would revert to CVC for hemodialysis. Nine (90%) parents reported being told by healthcare professional that an "AVF is better," but only four (40%) parents believed an AVF was "better for their child."
Conclusion: Psychosocial barriers persist in the transition of CVC patients to AVFs. Although both groups share similar concerns regarding AVFs, the majority of AVF patients remain satisfied with their type of access. These findings may be related to the significantly older age of the AVF group, possibly suggesting that older patients are more likely to understand the benefit of an AVF despite the body image concerns. Efforts should be focused on improving the education of younger HD patients and their families on the value of AVF.
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