Summary of NKF KDOQITM Clinical Practice Guidelines for Vascular Access, Update 20061

Summary of NKF KDOQITM Clinical Practice Guidelines for Vascular Access, Update 20061

Summary of NKF KDOQITMClinical PracticeGuidelines for Vascular Access, Update 20061

PURPOSE

To provide guidelines for clinical practice related to increasing theplacement of native fistulae, detecting access dysfunction beforeaccess thrombosis and implementing quality improvementprograms.

GOALS

●Early identification of patients with progressive kidney disease

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IDENTIFICATION AND PROTECTION OF POTENTIAL FISTULA CONSTRUCTION SITES Recommended evaluations:

●History and physical examination

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Duplex ultrasound of the upper-extremity arteries and veins Central vein evaluation (if history of a previous catheter orpacemaker)

Identification and protection of potential fistula constructionsites

Early access dysfunction detection

Implementation of procedures to maximize access longevity

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CKD stage 4 or 5, forearm and upper-arm veins suitable forplacement of vascular access should not be used for:●Venipuncture

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Placement of intravenous (IV) catheters Subclavian catheters

Peripherally inserted central catheter lines (PICCs)

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)CMS Phase III ESRD Clinical Performance Measures for vascularaccess list 5 measures for vascular access which can be distilled into3 key points: avoid central catheterization, maintain existing accessby detecting impending failure, and maximize creation of

functional autogenous AV fistulae (AVF). The CMS nationwidestretch goal of increasing the percentage of hemodialysis patientsusing AVF is 66% by 2009.

EARLY IDENTIFICATION OF PATIENTS WITHPROGRESSIVE KIDNEY DISEASE

Patients with a glomerular filtration rate (GFR) less than 30mL/min/1.73 m2(CKD stage 4) should be educated on allmodalities of kidney replacement therapy options, includingtransplantation, so that timely referral can be made for theappropriate modality and placement of a permanent dialysisaccess, if necessary. Patients should have a functional permanentaccess at the initiation of dialysis therapy.

Recommended timeframes for access placement prior to initiationof dialysis:

●Fistula: At least 6 months prior, prefer wrist (radiocephalic) orelbow (brachiocephalic) primary fistula

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EARLY ACCESS DYSFUNCTION DETECTION

Prospective surveillance of fistulae and grafts for hemodynamicallysignificant stenosis, when combined with correction of the

anatomic stenosis, may improve patency rates and may decreasethe incidence of thrombosis. NKF KDOQI guidelines

recommend an organized monitoring/surveillance approach withregular assessment of clinical parameters of the AV access andhemodialysis (HD) adequacy. Data from the clinical assessmentand HD adequacy measurements should be collected and

maintained for each patient's access and made available to all staff.The data should be tabulated and tracked within each HD centeras part of a Quality Assurance (QA)/CQI program.

Summary of monitoring and surveillance tools:Physical examination (monitoring)

■Inspection: Assess for bleeding/swelling/clotting/cannulation problems■Palpation■Auscultation

Surveillance of graftsPreferred:

■Intra-access flow using sequential measurements with trend analysis

■Directly measured or derived static venous dialysis pressure ■Duplex ultrasound Surveillance of fistulaPreferred:

■Direct flow measurements ■Duplex ultrasound

Acceptable:

■Recirculation using a non–urea-based dilutional method ■Static pressures, direct or derived

Graft: In most cases, at least 3 to 6 weeks prior, prefer forearmloop graft, to a straight configuration

Peritoneal dialysis (PD) catheter should be placed at least 2weeks prior

Avoid long term central venous catheters

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Summary of NKF KDOQITM Clinical Practice Guidelines for Vascular Access, Update 20061

IMPLEMENTATION OF PROCEDURES TO MAXIMIZE ACCESS LONGEVITY

The use of aseptic technique, appropriate cannulation methods,the timing of fistula and graft cannulation, and early evaluation ofimmature fistulae are all factors that may prevent morbidity andmay prolong the survival of permanent dialysis accesses.

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Catheters and ports should be evaluated when they fail to attainand maintain an extracorporeal blood flow of 300 mL/min orgreater at a prepump arterial pressure more negative than –250mm Hg

Treatment of an infected HD catheter or port should be basedon the type and extent of infection

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Use aseptic technique for all cannulation and catheter accessionprocedures

Implement cannulation protocols

-Cannulation training tools are available through

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CONTINUOUS QUALITY IMPROVEMENT (CQI)

●Each center should establish a database and CQI process totrack the types of accesses created, complication rates for theseaccesses and outcomes

-Implement periodic monitoring of accesses to detect hemodynamically significant stenoses before thrombosis-Evaluate incidence of catheter related infections and type of organism responsible for infections in order to improve catheter care

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Use the Rule of 6s as a guideline for determining fistulafunction:

-Flow greater than 600 mL/min -Diameter at least 0.6 cm -Discernible margins-No more than 0.6 cm deep

Create a vascular access team to initiate and supportimprovements in the staff’s skill set

Increase the percentage of patients with native or primary AVFsby implementing the 11 Change Concepts of Fistula First

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Grafts generally should not be cannulated for at least 2 weeksafter placement (composite PU graft should not be cannulatedfor at least 24 hours after placement) and not until swelling hassubsided

A program should be in place to detect delays in fistulamaturation. Evaluate access no later than 6 weeks afterplacement

Potential complications such as persistent swelling, inadequateflow, stenosis, aneurysm, ischemia and infection must beresolved through appropriate intervention

Indications for preemptive percutaneous transluminalangioplasty (PTA):

A fistula with a greater than 50% stenosis in either the venousoutflow or arterial inflow, in conjunction with clinical orphysiological abnormalities, should be treated with PTA orsurgical revision

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Patients with extremity edema that persists beyond 2 weeks aftergraft placement should undergo an imaging study (includingdilute iodinated contrast) to evaluate patency of the centralveins. The preferred treatment for central vein stenosis is PTA.Stenoses that are associated with AVGs should be treated withangioplasty or surgical revision if the lesion causes a greater than50% decrease in the luminal diameter and is associated withclinical/physiological abnormalities

Treatment of thrombosis and associated stenosis:

-Each institution should determine which procedure,percutaneous thrombectomy with angioplasty or surgicalthrombectomy with AVG revision, is preferable based uponexpediency and physician expertise at that center

APPLICATION OF GUIDELINES

The above summary of guidelines pertains to adult hemodialysispatients. Pediatric indicators may differ from these guidelines.NKF KDOQI disclaimer states, “These Clinical PracticeGuidelines (CPGs) and Clinical Practice Recommendations

(CPRs) are based upon the best information available at the timeof publication. They are designed to provide information and assistdecision-making. They are not intended to define a standard ofcare, and should not be construed as one. Neither should they beinterpreted as prescribing an exclusive course of management.Variations in practice will inevitably and appropriately occur whenclinicians take into account the needs of individual patients,

available resources, and limitations unique to an institution or typeof practice. Every health-care professional making use of theseCPGs and CPRs is responsible for evaluating the appropriatenessof applying them in the setting of any particular clinical situation.”REFERENCE

1. National Kidney Foundation. KDOQI Clinical Practice Guidelines andClinical Practice Recommendations for 2006 Updates: Hemodialysis

Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis48 (suppl 1). S1-S322, 2006

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