Updated Vascular Access Guidelines Put Emphasis on Patients’ Individual Needs

The Kidney Disease Outcomes Quality Initiative (KDOQI) Practice Guideline for Vascular Access has guided nephrologists in choosing vascular access for dialysis patients since 2006. Now the first update in 13 years shifts away from recommending a single “best practice” approach toward making individualized plans based on patient preferences and their evolving needs over a lifetime.

“We needed to make some changes to impact patient outcomes,” says Tushar Vachharajani, MD, Cleveland Clinic’s Director of Interventional Nephrology and Global Nephrology and a member of the KDOQI guidelines writing committee. “Nothing we have done has improved the primary vascular access failure rate. At least we can improve the quality of dialysis for our patients.”

Changing focus

When the first guidelines were issued, fistulas were considered the most reliable form of vascular access for hemodialysis. Since that time, changes in patient demographics, increased longevity and improvements in the care of patients with end-stage kidney disease (ESKD) underscored the need to reexamine best practices.

“We had tried to create as many fistulas as possible to minimize the use of grafts and catheters, but a 25% to 40% incidence of primary fistula failure remained,” says Dr. Vachharajani.

In 2016, the KDOQI convened a guidelines writing group comprised of physicians from multiple disciplines to review vascular access care. A separate evidence review team was charged with combing the literature for papers on every aspect of vascular access and supplying evidence to the writing group. Where evidence was insufficient, the team discussed personal experience and reviewed anecdotal evidence to make recommendations.

The three-year process culminated in a draft that was released for input by the nephrology and dialysis communities. After incorporating comments, the process was repeated. The resulting 164-page document, published on April 1 in the American Journal of Kidney Diseases, reflects the work group’s thoughtful, practical and evidence-based recommendations for meeting the dialysis needs of individuals.

A fresh approach

The new guidelines take a fresh, patient-centered approach to vascular access.

“We advocate the right access for the right patient at the right time for the right reason,” Dr. Vachharajani quips. “A fistula is not always optimal. Patients may choose to start dialysis with a catheter, accepting the risks involved, or may not necessarily be the right candidates for a functioning fistula. Some patients may prefer to start on peritoneal dialysis.”

The development of an ESKD life plan urges providers to think ahead, while taking into account an individual’s needs and preferences.

“We recommend providers create and regularly update a life plan for each patient. This plan should be designed to achieve the most suitable dialysis access type, while considering how the patient’s dialysis needs may change in the future,” he explains.

A work in progress

While the revised guidelines are the result of rigorous and sophisticated evaluation and integration of data accumulated over several decades, the writing group recognized the existence of knowledge gaps that need to be filled. This leaves room for research projects that will produce new evidence and innovations in dialysis.

“If we remember to keep the patient at the center of the discussion, the concepts will fall into place very nicely,” he says.