The publication of the second update of the Clinical Practice Guidelines (CPGs) and Clinical Practice Recommendations (CPRs) for Vascular Access represents the second update of these guidelines since the first guideline on this topic was published in 1997. The first set of guidelines established the importance of placing fistulae in long-term hemodialysis patients. Several of these guidelines have been selected as clinical performance measures by regulatory agencies to drive the process of quality improvement in long-term dialysis patients, and an initiative in the United States called “Fistula First” recently was started in an effort to increase the percentage of patients who have an arteriovenous fistula placed for long-term hemodialysis therapy.
Several major changes have occurred since the publication of the first set of guidelines. First, a number of clinical trials have been performed to determine the efficacy of different methods of identifying an access that is beginning to fail. Thus, this update of the guideline includes a substantial revision of accepted methods for access dysfunction detection. Second, cannulation techniques have been updated to include the importance of training staff in cannulation techniques and the appropriate uses of the buttonhole technique for arteriovenous fistulae. Finally, urokinase was removed from the market and other thrombolytic agents have been developed to assist with reestablishing patency in dialysis catheters. The use of these newer agents is addressed in this update.
This document has been divided into 3 major areas. The first section consists of guideline statements that are evidence based. The second section is a new section that consists of opinion-based statements that we are calling “clinical practice recommendations,” or CPRs. These CPRs are opinion based and are based on the expert consensus of the Work Group members. It is the intention of the Work Group that the guideline statements in Section I can be considered for clinical performance measures because of the evidence that supports them. Conversely, because the CPRs are opinion based, and not evidence based, they should not be considered to have sufficient evidence to support the development of clinical performance measures. The third section consists of research recommendations for these guidelines and CPRs. We have decided to combine all the research recommendations for the guidelines into 1 major section and also have ranked these recommendations into 3 categories: critical importance, high importance, and moderate importance. Our intended effect of this change in how the research recommendations are presented is to provide a guidepost for funding agencies and investigators to target research efforts in areas that will provide important information to benefit patient outcomes.
This final version of the Clinical Practice Guidelines and Recommendations for Vascular Access has undergone extensive revision in response to comments during the public review. While considerable effort has gone into their preparation during the past 2 years and every attention has been paid to their detail and scientific rigor, no set of guidelines and clinical practice recommendations, no matter how well developed, achieves its purpose unless it is implemented and translated into clinical practice. Implementation is an integral component of the Kidney Disease Outcomes Quality Initiative (KDOQI) process and accounts for the success of its past guidelines. The Kidney Learning System (KLS) component of the National Kidney Foundation is developing implementation tools that will be essential to the success of these guidelines.
In a voluntary and multidisciplinary undertaking of this magnitude, many individuals make contributions to the final product now in your hands. It is impossible to acknowledge them individually here, but to each and every one of them, we extend our sincerest appreciation. This limitation notwithstanding, a special debt of gratitude is due to the members of the Work Group and their co-chairs, Anatole Besarab of Henry Ford Hospital and Jack Work of Emory University. It is their commitment and dedication to the KDOQI process that has made this document possible.
Adeera Levin, MD, FACP
Michael Rocco, MD, MSCE