KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

Abstract

Background. Although older adults encompass almost half of patients with advanced chronic kidney disease, it remains unclear which long-term hemodialysis vascular access type, arteriovenous fistula or arteriovenous graft, is optimal with respect to effectiveness and patient satisfaction. Clinical outcomes based on the initial AV access type have not been evaluated in randomized controlled trials. This pilot study tested the feasibility of randomizing older adults with advanced kidney disease to initial arteriovenous fistula versus graft vascular access surgery. Methods: Patients 65 years or older with pre-dialysis chronic kidney disease or incident end-stage kidney disease and no prior arteriovenous vascular access intervention were randomized in a 1:1 ratio to undergo surgical placement of a fistula or a graft after providing informed consent. Trial feasibility was evaluated as (i) recruitment of ≥70% of eligible participants, (ii) ≥50% to 70% of participants undergo placement of index arteriovenous access within 90 to 180 days of enrollment, respectively, (iii) ≥80% adherence to study-related assessments, and (iv) ≥70% of participants who underwent index arteriovenous access placement will have a follow-up duration of ≥12 months after index surgery date. Results: Between September 2018 and October 2019, 81% (44/54) of eligible participants consented and were enrolled in the study; 11 had pre-dialysis chronic kidney disease and 33 had incident or prevalent end-stage kidney disease. After randomization, 100% (21/21) assigned to arteriovenous fistula surgery and 78% (18/23) assigned to arteriovenous graft surgery underwent index arteriovenous access placement within a median (1st, 3rd quartile) of 5.0 (1.0, 14.0) days and 13.0 (5.0, 44.3) days, respectively, after referral to vascular surgery. The completion rates for studyspecific assessments ranged between 40.0 and 88.6%. At median follow-up of 215.0 days, 5 participants expired, 7 completed 12 months of follow-up, and 29 are actively being followed. Assessments of grip strength, functional independence and vascular access satisfaction were completed by >85% of patients who reached pre-specified post-operative assessment time point. Conclusions: Results from this study reveal it is feasible to enroll and randomize older adults with advanced kidney disease to one of two different arteriovenous vascular access placement surgeries. 4 The study can progress with minor protocol adjustments to a multisite clinical trial. Trial registration: Clinical Trials ID: NCT03545113. Registered June 4, 2018. Key Messages Regarding Feasibility 1) What uncertainties existed regarding the feasibility? No trial has objectively evaluated clinical outcomes in patients with advanced kidney disease based on the type of first hemodialysis arteriovenous vascular access placed. Hence, the feasibility of randomly assigning these patients to different surgical interventions for dialysis vascular access are unknown. Because this study focused on older patients with chronic disease, uncertaint...

Point‐of‐care ultrasound use for vascular access assessment and cannulation in hemodialysis: A scoping review

“…More recently, the Kidney Disease Outcomes Quality Initiative in the United States has released updated vascular access guidelines 49 . Based on expert opinion, these guidelines state it “is reasonable to use ultrasound to help determine direction of flow and proper needle placement in the AV access of select patients as needed and performed by trained operators, to prevent cannulation complications.” 49 …”

“…Prospective clinical trials are required with a specific focus on the indications for use of POCUS, comparison with the standard practice of blind cannulation, and measurement of outcomes related to the dependence on CVAD and optimal POCUS techniques 5 . New guidelines call for “rigorous study of use of ultrasound‐guided cannulation—its safety, efficacy, and impact in busy dialysis units.” 49 …”

Should Buttonhole Cannulation of Arteriovenous Fistulas Be Used? Moderator Commentary

“…A recent prospective observational multicenter study showed a much higher risk of bacteremia with BHC cannulation-eight fold as compared to RLC-which led to yet another call to abandon use of BHC (12,13). Additionally, data from the (15). KDOQI also suggests that when BHC is performed, the use of devices to facilitate cannulation should be at the discretion and expertise of the cannulator.…”

Comparing Non-invasive Diagnostic Methods for Arteriovenous Fistula Stenosis: A Prospective Study

“…A liations 1 Nephrology Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University Tables Table 1 Baseline demographic data. Number of patients, n 23 Sex male/female, n…”

“…Reliable, arterio-venous access is of critical importance for patients with end-stage renal disease (ESRD) on hemodialysis (HD). An arteriovenous stula (AVF) is the ideal hemodialysis vascular access, because of a lower infection rate and associated morbidity and mortality as compared to either arteriovenous graft (AVG) or central venous catheter (CVC) [1,2] . However, long term AVF patency is a signi cant problem; recently studies revealed one-year AVF survival of 40-90% [3][4][5][6].…”