GUIDELINES FOR VASCULAR ACCESS
III. NKF-KDOQI CLINICAL PRACTICE GUIDELINES FOR VASCULAR ACCESS: UPDATE 2000
NOTE: The citation for these guidelines should read as follows: National Kidney Foundation. KDOQI Clinical Practice Guidelines for Vascular Access, 2000. Am J Kidney Dis 37:S137-S181, 2001 (suppl 1)
ADEQUATE CARE OF an end-stage renal disease (ESRD) hemodialysis dependent patient requires constant attention to the need to maintain vascular access patency. An ideal access delivers a flow rate adequate for the dialysis prescription, has a long use-life, and has a low rate of complications (eg, infection, stenosis, thrombosis, aneurysm, and limb ischemia). Although no current access type fulfills all of these criteria, the native arteriovenous (AV) fistula comes the closest to doing so. Studies demonstrate that native accesses have the best 4 to 5 year patency rates and require the fewest interventions compared to other access types.3,4 Yet, in the United States, the growth of the ESRD hemodialysis program has been accompanied by a decreased use of native AV fistulae and an increased use of synthetic AV grafts and silastic cuffed central catheters for permanent hemodialysis access.5,6 The United States Renal Data System (USRDS) recently reported that insertion of polytetrafluoroethylene (PTFE) grafts occurred almost twice as often as construction of native accesses in the 1990 incident cohort of patients.6 Significant geographic variation in the ratio of native fistula construction to graft placement has also been noted.
The substitution of synthetic grafts for native fistulae has increased patient care costs in part due to the increased number of procedures needed to maintain patency of grafts compared to native fistulae.7 In addition, late referral of patients for permanent access placement is reflected in patient hospitalizations. In some regions, up to 73% of patients are hospitalized for initiation of hemodialysis, almost invariably for temporary dialysis catheter access.8 Early referral of chronic kidney failure patients to a nephrologist allows for access planning and thus increases the probability of AV fistula formation.
As a result of current practice patterns, hemodialysis access failure is a major cause of morbidity for patients on hemodialysis. Various reports indicate that a high percentage of ESRD patient hospitalizations are due to vascular access complications.6,9–11 The USRDS reports that hemodialysis access failure is the most frequent cause of hospitalization among ESRD patients, and in some centers it accounts for the largest number of hospital days.12 Reports also indicate a decreasing interval between placement of a vascular access and a surgical procedure needed to restore patency,7,10 with significant costs to restore patency.6,12 It has been demonstrated that an aggressive policy for monitoring AV graft patency extends graft life and minimizes graft thrombosis (see Guideline 10: Monitoring Dialysis AV Grafts for Stenosis). Thus, much access-related morbidity and associated costs are avoidable. The number of interventions required to maintain access patency may be reduced further by the use of native fistulae rather than AV grafts.
After evaluating all of the available data on vascular access, the Vascular Access Work Group concluded that quality of life and overall outcomes for hemodialysis patients could be improved significantly by achieving two primary goals:
1. Increasing the placement of native AV fistulae.
2. Detecting access dysfunction prior to access thrombosis.
The available data argue strongly that such an approach should enhance long-term access function and reduce the costs associated with the maintenance of access patency. To achieve these objectives, the Work Group has developed this set of practice guidelines as well as strategies for implementation. At the core of these guidelines is the goal of early identification of patients with progressive kidney disease and the identification and protection of potential native fistula construction sites–particularly sites using the cephalic vein–by members of the healthcare team and patients.
Once access has been constructed, dialysis centers need to employ a multifaceted quality assurance (QA) program to detect vascular accesses at risk, track access complication rates, and implement procedures that maximize access longevity. The Work Group has developed explicit guidelines regarding which tests to use to evaluate a given access type and when and how to intervene to reduce thrombosis and underdialysis. The Work Group believes that the guidelines are reasonable, appropriate, and achievable. Attainment of these goals will require the concerted efforts of not only practicing nephrologists, but also nephrology nurses, access surgeons, vascular interventionalists, patients, and other members of the healthcare team.
Evidence-Based Versus Opinion-Based Guidelines
To the greatest extent possible, these guidelines are based on evidence in the published literature. Where evidence is not available, the guidelines are based on the opinion of the Work Group. For each guideline, there is a clear indication of whether the guideline is based on evidence, opinion, or both.
© 2001 by the National Kidney Foundation, Inc.
KDOQI 2006 Update for Vascular Access
NKF KDOQI Guidelines
NKF 2006 Updates Clinical Practice Guidelines and Recommendations