KDOQI Vascular Access Guidelines A Clinician’s Perspective

In 1996, the Kidney Disease Outcomes Quality Initiative (KDOQI) was created by a multidisciplinary group of physicians with the support of the National Kidney Foundation. It was the first literature-based practice guideline and was developed with the hope of measurably improving the quality of life and clinical outcomes for dialysis patients. To achieve this objective, four work groups were created, one of which was dedicated to clinical practice guidelines related to vascular access for patients requiring hemodialysis (HD) (1). The vascular access guidelines have since undergone three updates: in 2000, 2006, and most recently, in 2019.

The 2019 vascular access guidelines have been expanded to 26 separate sets of guidelines that were based on review of more than 4600 publications. As with the earlier versions, evidence-based and opinion-based guidelines were differentiated; in the 2019 guidelines, each recommendation was qualified by using a “Grading of Recommendations Assessment, Development, and Evaluation” (GRADE) approach. Furthermore, when applicable, each guideline statement was accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research (2).

From a clinician perspective, it is gratifying to see how the 2019 vascular access initiatives and guidelines have progressed from stringent recommendations, such as mandating specific thresholds of fistula or catheter prevalence, to a more clinically based approach that takes into consideration the individual patient context, such as patients with poor long-term prognoses and short life expectancies.

Since the Fistula First Initiative emerged from the 2001 KDOQI vascular access guideline update, a significant increase in the utilization of arteriovenous fistulas (AVF) in HD patients has been reported, from <20% of US end stage kidney disease (ESKD) patients at the time of the original guidelines to >60% prevalence of AVF in the US HD population today. A widely held opinion, however, is that these guidelines have, at times, also had a negative impact on patient care. This negative impact is mainly attributed to unintended outcomes, such as the rising numbers of upper-arm fistulas, which may negatively impact a patient’s future vascular access options. Another unintended consequence is that whereas the number of AVF creations has significantly increased, it is not necessarily paralleled by subsequent use of AVFs. The increase in fistula creations has been mainly due to a reduction in initial arteriovenous graft (AVG) creations and use, rather than a reduction in central venous catheter (CVC) utilization; CVC use remains unchanged and exceeds 80% for incident HD patients, perhaps due to the high fistula failure rate (3).

The 2019 KDOQI vascular access guidelines have a much more patient-focused approach that recognizes the differences in practice patterns among clinicians, while still focusing on providing high-quality standards that offer dialysis access choices customized to individual patients’ goals and preferences. The ideal access is no longer “a fistula”; it is any type of access that is reliable, can deliver adequate dialysis without complications, and is suitable for each individual patient’s needs: “The right access, in the right patient, at the right time, for the right reasons.”

The “ESKD Life-Plan,” adopted in the 2019 document (Guideline 1), provides a patient’s individualized lifetime map of dialysis modalities by creating a “P-L-A-N” (patient life-plan first, then access needs). The comprehensive vascular access plan includes an access creation plan, contingency plan, succession plan, and underlying vessel preservation plan (2).

The guidelines also have renewed approaches of older topics to optimize the patient’s access options. For example, they propose a surprising sequence of dialysis catheter locations, prioritizing femoral catheterization over subclavian catheterization in urgent dialysis start situations until the AV access or peritoneal dialysis (PD) catheter can be quickly created and used, which is justified by the potential to limit central stenosis. It is worthwhile taking the time to read the detailed justifications to the guideline’s statements.

The inclusion of the subclavian vein as a possible site was also unexpected in light of the well-reported central vein stenosis following subclavian vein catheterization. However, from a clinician perspective, subclavian vein catheterization on an extremity, where all vascular access options have been exhausted, is much more beneficial than an internal jugular catheterization on the ipsilateral side of newly created vascular access. Here, we see how the guidelines are practical and aligned with a clinician’s perspective. A note under the statement reads, “If one side has pathology that limits AV access creation but allows for CVC insertion, this side should be used for the CVC to preserve the other side for AV access creation” (4).

The new guidelines emphasize the clinical implications of their implementation. A good example is the new definition of CVC dysfunction, which takes advantage of the flexibility in various HD prescriptions, according to the duration and frequencies of dialysis regimens. Moving away from the rigid cutoff of the “>300 mL⁄min” recommendation would decrease unnecessary or invasive interventions, such as tissue plasminogen activator (TPA) administration or catheter exchange based solely on a flow rate.

There are other differences between the prior guidelines and the current ones. The current guidelines have the benefit of almost 15 years of ample literature, including controlled randomized trials and a more rigorous evidentiary database for vascular access. Table 1 highlights some of these differences.

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Whereas one might argue that some of the updated guidelines continue to support recommendations solely based on expert opinion, such as maintenance angioplasty of dialysis access to address “access flow dysfunction” complications, clinicians utilizing such opinion-based guidelines might avoid a significant increase in patient morbidity, as well as cost to the healthcare system associated with vascular access dysfunction. This seems appropriate until we have better evidence-based recommendations.

In summary, the updated 2019 vascular access guidelines have gained refinement in development, grading, and reporting. The expected conveyance from population-based practice to patient-centered practice would substantially affect overall clinical vascular access management and patient outcomes for years to come. These guidelines are a welcome and refreshing change that can be practically implemented by clinicians.

References

1. 

NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997; 30:S179–S183. PMID: 9339150

2. 

Lok CE, et al KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis 2020; 75:S1–S164. https://doi.org/10.1053/j.ajkd.2019.12.001

3. 

Lee T. Fistula First Initiative: historical impact on vascular access practice patterns and influence on future vascular access care. Cardiovasc Eng Technol 2017; 8:244–254. doi: 10.1007/s13239-017-0319-9

4. 

Agarwal AK, et al Central vein stenosis: a nephrologist’s perspective. Semin Dial 2007; 20:53–62. doi: 10.1111/j.1525-139X.2007.00242.x

September 2020: Volume 12, Issue 9