Charmaine E. Lok
BOSTON — Revisions to guidelines for vascular access placement in the patient with ESKD – the first in 10 years – place a greater emphasis on matching patients’ care plans and modality options with the access choice.
“The prior messages were excellent with ‘Fistula First,’ and we are still embracing ‘Fistula First,’” Charmaine E. Lok, MD, MSc, FRCP(C), said at the National Kidney Foundation Spring Clinical Meetings, here. “We are still going to use that concept in patients where it is appropriate, [but] it is going to be more than just ‘Fistula First,’ and it is going to be more than ‘Catheter Last’ because there are patients where the catheter is appropriate.”
Lok is professor of medicine at the University of Toronto and senior scientist at the Toronto General Research Institute. She chaired the Kidney Disease Outcomes Quality Initiative (KDOQI) committee responsible for revising the vascular access guidelines, last updated in 2008. Vice chairs of the guideline work group were Alexander Yevzlin, MD, and Surendra Shenoy, MD.
Lok said the new philosophy is to promote individualized decision-making on access placement, taking the approach of “placing the right access, in the right patient, at the right time, and for the right reasons,” she said, and developing a patient life-plan for access needs which steers access choices based on a patient’s modality choice and goals while on dialysis.
The revised guidelines include 168 statements, 38 more than the 2006 guidelines. KDOQI committee members who reviewed evidence regarding access placement could develop statements that included words like “recommends” or “suggests,” based on the evidence, or indicate in the guidelines that “there is inadequate evidence” or KDOQI “considers it reasonable” to offer guidance based on the work group’s review of the literature.
The new guidelines also include illustrative cases on choosing an access, coverage of new materials used for access devices, the use of anesthesia for arteriovenous access placement, recommendations on the use of stent grafts, and discussion of central venous stenosis, both symptomatic and asymptomatic.
New and revised definitions of access use
The guidelines also revise definitions of the vascular access process and function, as well as introduce new definitions. The workgroup re-defined arteriovenous access and catheter dysfunction, the diagnosis of catheter-related bacteremia and what is considered hemodynamically significant in defining an access lesion. New definitions include access circuit primary patency, treatment area primary patency, complications defined by thrombotic and non-thrombotic flow, and infiltration problems based on the severity of cannulation injury. – by Kristine Houck, MA, ELS, and Mark E. Neumann
Lok C. KDOQI Vascular Access Guidelines in 2019: What’s new? Presented at: National Kidney Foundation Spring Clinical Meetings; May 8-12, 2019; Boston.
Disclosure: Lok reports no relevant financial disclosures.