KDOQI CLINICAL PRACTICE GUIDELINE FOR VASCULAR
ACCESS: 2019 UPDATE
Charmaine E. Lok, Thomas S. Huber, Timmy Lee, Surendra Shenoy, Alexander S. Yevzlin, Kenneth Abreo,
Michael Allon, Arif Asif, Brad C. Astor, Marc H. Glickman, Janet Graham, Louise M. Moist, Dheeraj K. Rajan,
Cynthia Roberts, Tushar J. Vachharajani, and Rudolph P. Valentini
Abstract
The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidencebased
guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a
great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI
Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary
practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage
kidney disease “Life-Plan” and related concepts, guidance on vascular access choice, new targets for arteriovenous
access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed
approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a
Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation
and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is
accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance,
implementation considerations, special discussions, and recommendations for future research.
In citing this document, the following format should be used: Lok CE, Huber TS, Lee T, et al; KDOQI Vascular
Access Guideline Work Group. KDOQI clinical practice guideline for vascular access: 2019 update. Am J
Kidney Dis. 2020;75(4)(suppl 2):S1-S164.
As they are designed to reflect the views and recommendations of the responsible KDOQI Work Group, based
on data from an independent evidence review team, and because they undergo both internal and public review,
KDOQI guidelines are not peer reviewed by AJKD.
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S1
Disclaimer
SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE
This Clinical Practice Guideline document is based on the best information available as of October 2016. It is designed to
provide information and assist decision making. It is not intended to define a standard of care and should not be
construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in practice
will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available
resources, and limitations unique to an institution or type of practice. Every health care professional making use of these
recommendations is responsible for evaluating the appropriateness of applying them in the setting of any particular
clinical situation. The recommendations for research contained in this document are general and do not imply a specific
protocol.
SECTION II: DISCLOSURE
All reported information is provided in the “Biographical and Disclosure” section of this journal supplement and is on
file at the National Kidney Foundation (NKF).
S2 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Work Group Membership
Charmaine E. Lok, MD, MSc, FRCP(C) (Chair, KDOQI Vascular Access Guidelines)
Professor of Medicine, University of Toronto
Director of Multi-care Kidney Clinics and Hemodialysis Program,
University Health Network
Senior Scientist, Toronto General Research Institute
Thomas S. Huber, MD, PhD (Editorial Committee) Timmy Lee, MD (Editorial Committee)
Professor of Surgery and Chief, Division of Vascular
Surgery, University of Florida College of Medicine
Professor of Medicine, Department of Medicine, Division of
Nephrology, and Department of Biomedical Engineering,
University of Alabama at Birmingham
Surendra Shenoy, MD, PhD (Vice Chair,
Guideline Scope)
Alexander S. Yevzlin, MD (Vice Chair, Guideline Scope)
Professor of Surgery and Director of the Living Donor
Transplantation Program, Washington University School of
Medicine
Professor of Medicine and Director of Interventional
Nephrology, University of Michigan
Kenneth Abreo, MD
Professor of Medicine, Chief, Division of Nephrology,
and Vice Chairman, Department of Medicine
LSU Health Shreveport School of Medicine
Michael Allon, MD
Professor of Medicine, Associate Director for Clinical Affairs
and Medical Director of Dialysis Operations, Division of Nephrology
University of Alabama at Birmingham
Arif Asif, MD, MHCM
Professor of Medicine, Chairman, Department of Medicine, Assistant Chief Medical Officer,
Jersey Shore Medical Center
Seton Hall-Hackensack Meridian School of Health
Neptune, New Jersey
Brad C. Astor, PhD, MPH
Professor, Departments of Medicine and Population Health Sciences
University of Wisconsin School of Medicine and Public Health
Marc H. Glickman, MD
Chief Medical Officer, Senior Vice President
Hancock Jaffe Laboratories
Irvine, California
Janet Graham, MHScN, CNeph(C)
Clinical Director of Nephrology, The Ottawa Hospital
Regional Director of Nephrology, Champlain LHIN Ontario Renal Network
Louise M. Moist, MD, MSc
Professor of Medicine, Epidemiology and Biostatistics
Associate Chair, Division of Nephrology
Western University
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S3
Dheeraj K. Rajan, MD, FRCP(C)
Professor of Radiology and Division Chief of Vascular and Interventional Radiology
University of Toronto
Cynthia Roberts, RN, CNN
Vascular Access Coordinator, Renal Research Institute, University of North Carolina at Chapel Hill
Nephrology and Hypertension Division
Tushar J. Vachharajani, MD
Clinical Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
Director of Interventional Nephrology and Director of Global Nephrology, Glickman Urological & Kidney Institute,
Cleveland Clinic
Rudolph P. Valentini, MD
Professor of Pediatrics, Chief Medical Officer, Children’s Hospital of Michigan (CHM), Wayne State University School
of Medicine
Evidence Review Team
University of Minnesota Department of Medicine
Minneapolis VA Center for Chronic Disease Outcomes Research, Minneapolis, MN, USA
Michelle Brasure, PhD, MSPH, MLIS, Program Manager and Medical Librarian
University of Minnesota School of Public Health
Nancy Greer, PhD, Senior Research Associate and Program Manager
Minneapolis VA Health Care System
Areef Ishani, MD, MS, Professor of Medicine, Chief of Primary Care at the Minneapolis VA Health Care System
Roderick MacDonald, MS, Senior Research Assistant
Minneapolis VA Health Care System
Victoria A Nelson, MSc, Research Fellow and Study Coordinator
University of Minnesota School of Public Health
Carin Olson, MD, MS, Medical Editor and Writer
University of Minnesota School of Public Health
Yelena Slinin, MD, MS, Nephrologist at Kaiser Permanente
Timothy J. Wilt, MD, MPH, Professor of Medicine and Project Director
Minneapolis VA Health Care System
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Organization Leadership
KDOQI LEADERSHIP
Michael V. Rocco, MD, MSCE
KDOQI Chair
Holly Kramer, MD, MPH
Vice Chair, Research, and President, National Kidney Foundation
Bernard Jaar, MD, MPH
Vice Chair, Education
Michael J. Choi, MD
Vice Chair, Policy, and Past President, National Kidney Foundation
KDOQI GUIDELINE DEVELOPMENT STAFF
Kerry Willis, PhD, Chief Scientific Officer
Jessica Joseph, MBA, Senior Vice President, Scientific Operations
Laura Brereton, MSc, KDOQI Project Director
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S5
Table of Contents
Boxes and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S8
Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S9
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S10
Chronic Kidney Disease Nomenclature Used by KDOQI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S15
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S16
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S17
Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S17
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S17
Literature Review and Evidence Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S18
Development of Guideline Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S18
Internal Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S19
External (Public) Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S19
SUMMARY OF GUIDELINE STATEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21
KDOQI CLINICAL PRACTICE GUIDELINE FOR VASCULAR ACCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S35
GUIDELINE 1. PATIENT FIRST: ESKD LIFE-PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S35
Statements: ESKD Life-Plan and Vascular Access Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S35
GUIDELINE 2. VASCULAR ACCESS TYPES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S39
Statements: AV Access: Indications for Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S39
Statements: Central Venous Catheters (CVC): Indications for Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S39
Statements: Vascular Access for Incident Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S40
Statements: Vascular Access in Prevalent HD Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S40
GUIDELINE 3. VASCULAR ACCESS LOCATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S45
Statements: AV Access Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S45
Statements: CVC Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S46
GUIDELINE 4. AV ACCESS TYPES AND MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S49
Statements: Novel AV Access Types and Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S49
GUIDELINE 5. CVC CONFIGURATION AND MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S51
GUIDELINE 6. TIMING, PREPARATION, AND PLANNING FOR CREATION/INSERTION OF DIALYSIS ACCESS . S52
Statements: Education on ESKD Modalities and Dialysis Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S52
Statements: Referral for AV Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S52
Statement: Vessel Preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S54
Statements: Multidisciplinary Team Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S55
GUIDELINE 7. PATIENT AND VESSEL EXAMINATIONS: PREPARATORY CONSIDERATIONS . . . . . . . . . . . . . . S57
Statements: Patient Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S57
Statements: Vessel Mapping for Vascular Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S58
Statements: Optimal Vessel Size of Artery and Vein for AV Access Creation . . . . . . . . . . . . . . . . . . . . . . . S59
GUIDELINE 8. AV ACCESS CREATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S59
Statement: Pre-Creation Infection Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S60
Statement: Use of Anesthesia for AV Access Creation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S60
Statement: AV Access Anastomotic Configuration and Apposition Methods . . . . . . . . . . . . . . . . . . . . . . . . S61
Statement: AV Access Anastomotic Suture Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S62
Statements: Use of Operator-Assisted Maneuvers for AV Access Maturation . . . . . . . . . . . . . . . . . . . . . . . S63
GUIDELINE 9. CVC INSERTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S64
Statements: Techniques and Other Considerations for Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S64
GUIDELINE 10. POST AV-ACCESS CREATION/CVC INSERTION CONSIDERATIONS . . . . . . . . . . . . . . . . . . . S66
Statement: AV Access Early Postoperative Considerations (0-30 days)–Early AV Access Complications . . . . . . S66
Statements: Postoperative AV Access Maturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S67
Statements: Timing of CVC Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S70
GUIDELINE 11. VASCULAR ACCESS USE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S71
Statement: Vascular Access General Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S72
Statements: AV Access Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S72
Statements: CVC System Connect and Disconnect Procedure Considerations . . . . . . . . . . . . . . . . . . . . . . . S74
GUIDELINE 12. AV ACCESS CANNULATION COMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S78
GUIDELINE 13. AV ACCESS FLOW DYSFUNCTION–MONITORING/SURVEILLANCE . . . . . . . . . . . . . . . . . . . S80
Statements: Appropriate Use of Monitoring/Surveillance for AV Access Flow Dysfunction . . . . . . . . . . . . . S80
Statements: Surveillance and Pre-emptive Intervention for AV Access Stenosis Not Associated With Clinical
Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S81
Statement: Pre-emptive Intervention for AV Access Stenosis Associated With Clinical Indicators . . . . . . . . . . S81
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GUIDELINE 14. AV ACCESS FLOW DYSFUNCTION–PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S88
Statements: Noninvasive Primary and Secondary Prevention of AV Access Flow Dysfunction . . . . . . . . . . . . S88
GUIDELINE 15. AV ACCESS FLOW DYSFUNCTION–CONFIRMATION AND TREATMENT . . . . . . . . . . . . . . . S91
Statements: Radiographic Confirmation of Clinically Significant AV Access Lesion . . . . . . . . . . . . . . . . . . . S91
Statement: General Treatment of Clinically Significant Stenosis or Thrombosed AV Access . . . . . . . . . . . . . S92
Statements: Treatment of Clinically Significant AV Access Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S92
Statements: Treatment of Thrombosed AV Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98
GUIDELINE 16. AV ACCESS INFECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100
Statements: AV Access Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100
GUIDELINE 17. AV ACCESS ANEURYSMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S102
Statements: AV Access Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S102
GUIDELINE 18. AV ACCESS STEAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S107
Statements: AV Access Steal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S107
GUIDELINE 19. OTHER AV ACCESS COMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S109
Statement: Management of AVG Seroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S109
Statement: Management of High-Flow AV Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S109
GUIDELINE 20. TREATMENT AND PREVENTION OF CVC COMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . S110
Statement: Monitoring/Surveillance of CVC Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S110
GUIDELINE 21. CATHETER DYSFUNCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S110
Statement: Definition of CVC Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S110
Statements: Pharmacologic Prevention of CVC Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S112
GUIDELINE 22. TREATMENT AND MANAGEMENT OF CVC DYSFUNCTION . . . . . . . . . . . . . . . . . . . . . . . S116
Statements: Medical Management of CVC Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S116
Statements: Mechanical Management of CVC Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S119
GUIDELINE 23. CATHETER-RELATED INFECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S120
Statements: Definitions of Catheter-Related Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S120
GUIDELINE 24. PREVENTION OF CVC-RELATED INFECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S122
Statement: General Prevention of CVC Infection and Use of Infection Surveillance Programs and Infection
Control Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S122
Statement: Surveillance of CVC Colonization and Preemptive CRBSI Management . . . . . . . . . . . . . . . . . . S122
Statements: Methods to Prevent CRBSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S123
GUIDELINE 25. TREATMENT OF CVC-RELATED INFECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S127
Statement: Management of the Patient With a CVC-Related Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . S127
Statement: Management of the CVC in a Patient With a CVC-Related Infection . . . . . . . . . . . . . . . . . . . . S127
GUIDELINE 26. OTHER VASCULAR ACCESS-RELATED COMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . S129
Statement: Treatment and Intervention of Asymptomatic Central Venous Stenosis Without Clinical Indicators S129
Statement: Investigation and Treatment of Symptomatic Central Venous Stenosis With Clinical Indicators . . S131
Statement: Management of CVC Fibrin Sheath Associated With Clinical Problems . . . . . . . . . . . . . . . . . . S131
KDOQI VASCULAR ACCESS GUIDELINES GOALS AND TARGETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S133
Rationale for Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S133
1. Establish and Document the Patient’s P-L-A-N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S133
2. Intervention Goal for AV Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S134
3. CRBSI Goal for Central Venous Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S134
Comparison to Prior KDOQI 2006 Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S134
RESEARCH RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S137
Future Research for Hemodialysis Vascular Access and Related Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . S137
Specific Research Recommendations Pertaining to Individual Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . S138
BIOGRAPHICAL AND DISCLOSURE INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S142
Guideline Development Work Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S142
Evidence Review Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S145
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S147
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Boxes and Tables
Box 1: Grade for Strength of Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S20
Box 2: Grade for Quality of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S20
Box 3. Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S135
Table 2.1: Access Type Comparison Studies Reviewed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S42
Table 3.1: Vessel Location by Distal to Proximal Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S47
Table 6.1: Suggested Indications for Creation/Insertion of a Vascular Access in Peritoneal Dialysis Patients . . . . S54
Table 7.1: Focused Preoperative Physical Examination for Vascular Access Planning and Creation . . . . . . . . . . S57
Table 7.2: Examples of Risk Factors For Which Vessel Mapping May Be Beneficial . . . . . . . . . . . . . . . . . . . . S58
Table 11.1: Circumstances Where Buttonhole Cannulation May Be Acceptable . . . . . . . . . . . . . . . . . . . . . . . S73
Table 11.2: Example of CVC Connect and Disconnect Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S77
Table 13.1: Routine AV Access Monitoring by Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82
Table 13.2: Clinical Indicators (Signs and Symptoms) Suggesting Underlying Clinically Significant Lesions
During Access Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83
Table 13.3: Additional Randomized Controlled Trials of AVG Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . S87
Table 13.4: Performance and Agreement Beyond Chance Between Physical Examination and Ultrasonography . S87
Table 14.1: Primary Outcomes Fish Oil Versus Placebo for AVF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S89
Table 15.1: Outcomes Paclitaxel-Coated Balloon Angioplasty in AVGs and AVFs . . . . . . . . . . . . . . . . . . . . . . S94
Table 15.2: Indications for Stent-Graft Use in AV Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S95
Table 17.1: Physical Examination Findings That Are Clinically Relevant to Differentiate Between Aneurysm/
Pseudoaneurysm That Do Not Require Urgent Intervention and Those of Urgent Concern. . . . . . S105
Table 18.1: Strategies to Reduce the Incidence of AV Access Steal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S107
Table 18.2: Clinical Predictors of AV Access Steal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S108
Table 18.3: Signs and Symptoms of Steal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S108
Table 18.4: Treatment Options for AV Access Steal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S108
Table 23.1: Definitions of CVC-Related Blood Stream Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S120
Table 23.2: Definitions of CVC Exit Sites and Tunnel Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S121
Table 24.1: Intraluminal Strategies: Effect of Antibiotic and Antimicrobial Catheter Lock Solutions on CRBSI:
Summary of Randomized Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S124
Table 26.1: Signs and Symptoms (Clinical Indicators) of Central Venous Stenosis . . . . . . . . . . . . . . . . . . . . S129
S8 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Abbreviations and Acronyms
2D 2-dimensional
ACPP Access circuit primary patency
AEC Allogenic endothelial cells
AKI Acute kidney injury
AV Arteriovenous
AV access Arteriovenous access: Refers to both a hemodialysis arteriovenous fistula and arteriovenous graft
AVF Arteriovenous fistula
AVG Arteriovenous graft
BAM Balloon-assisted maturation
BMI Body mass index
CDC Centers for Disease Control and Prevention
CFD Computational fluid dynamics
CFU Colony-forming unit
CI Confidence interval
CKD Chronic kidney disease
CRBSI Catheter-related bloodstream infection
CRI Catheter-related infection
CT Computed tomography
CVC Central venous catheter; in the guidelines will refer to hemodialysis catheter, and assume tunneled, cuffed
central venous catheter unless otherwise stated
CVS Central vein stenosis
DVP Dynamic venous pressure
eGFR Estimated glomerular filtration rate
FDA US Food and Drug Administration
GFR Glomerular filtration rate
HD Hemodialysis
HR Hazard ratio
IDSA Infectious Diseases Society of America
IJ Internal jugular vein
INR International normalized ratio
JAS Juxta-anastomotic stenosis
KDOQI Kidney Disease Outcomes Quality Initiative
KRT Kidney replacement therapy
MRI Magnetic resonance imaging
NKF National Kidney Foundation
NS Not significant
NT-CVC Nontunneled, noncuffed central venous catheter
OR Odds ratio
PCB Paclitaxel drug-coated balloon
PD Peritoneal dialysis
PET Positron emission tomography
PICC Peripherally inserted central catheter
PTA Percutaneous balloon angioplasty
PTFE Polytetrafluoroethylene
Qa Access blood flow
Qa/CO The ratio of access blood flow (mL/min) to cardiac output (mL/min)
Qb Blood pump flow delivered to the dialyzer
QOL Quality of life
RCT Randomized controlled trial
RR Relative risk
SVC Superior vena cava
SVP Static venous pressure
TAPP Treatment area primary patency
TMP-SMX Trimethhoprim/sulfamethoxazole or cotrimoxazole
TPA Tissue plasminogen activator
UDM Ultrasound dilution method
URR Urea reduction ratio
USRDS United States Renal Data System
VA Vascular access
VAC Vascular access coordinator
VAT Vascular access team
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S9
Glossary
Acronecrosis: Gangrene occurring in the distal part of the extremities, usually the fingertips and toes.
Anastomosis: A communication between an artery and a vein by surgical or endovascular techniques.
Aneurysm: An abnormal dilation of the blood vessel or part of the vessel wall; in the case of vascular access, it may result from disease
or trauma of the vessel wall.
Antibiotic lock: Interdialytic instillation and dwelling (“locking”) of an antibiotic containing solution into the lumen of a dialysis
catheter.
Antimicrobial: Any agent capable of destroying or inhibiting the growth of microorganisms.
Antimicrobial lock: Interdialytic instillation and dwelling (“locking”) of an antimicrobial solution into the lumen of a dialysis
catheter.
Antiseptic: Any agent capable of preventing infection by inhibiting the growth of microorganisms.
AV (arteriovenous) access abandonment: When a vascular access can no longer be used for prescribed 1 or 2 needle dialysis because it
is unable to provide adequate flows and/or is deemed unsafe for the patient, and the associated problem cannot be corrected by any
intervention, including medical, surgical, or radiologic interventions or rest.1
A checklist can be used to confirm abandonment as follows:
AV access creation: The connection of an artery and vein for the purposes of establishing hemodialysis access.
Cannulation: The insertion of cannulate (a needle with a lumen) or angiocaths into a vascular vessel. The main forms of cannulation
are as follows:
 Buttonhole technique cannulation: The cannulation into the exact same puncture site and needle track tunnel developed by
repeated cannulation at the same location, angle, and depth between the skin and access vein. The scar tissue tunnel track allows
the needle to pass through to the outflow vein or conduit of the AV access following the same path with each cannulation time.
Typically used in autogenous arteriovenous fistula and may be acceptable in grafts made of nonautogenous biologic material
such as bovine. This type of cannulation should not be used for accessing arteriovenous graft made of synthetic material such as
polytetrafluoroethylene (PTFE).
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 Constant-site technique cannulation: Another term for buttonhole cannulation. This should NOT be confused with general area
cannulation. General area cannulation is neither rope ladder nor buttonhole cannulation, whereby new arterial and venous needle
insertions are chronically inserted within close proximity (eg, millimeters) of prior insertions each time, that is, always in the
same general areas. This poor technique leads to AV access aneurysms and damage and should be avoided.
 Rope-ladder (also known as step-ladder) cannulation: The cannulation needle sites for both arterial and venous needles are
rotated along the length of the AV access each dialysis to reduce vessel damage.
Catheter: A device providing access to the central veins or right atrium, permitting high-volume flow rates.
Clinically significant lesion: One that contributes to clinical signs and symptoms (see AV Access Monitoring Table 13.2) without
other cause, with or without a sustained change in surveillance measurements (eg, change in blood flow [Qa] or venous pressures) in
the dialysis access circuit. Such a lesion is found during monitoring of vascular access (surveillance findings are supplementary) and
shows >50% narrowing relative to adjacent normal vein diameter by angiography or ultrasound.
Clinical monitoring: Monitoring refers to the examination and evaluation of the access by means of physical examination or check to
detect clinical signs that suggest the presence of AV access flow dysfunction, other dysfunction, or pathology. These abnormal clinical
signs may include arm swelling, changes in the access bruit or thrill, or prolonged bleeding after dialysis (Tables 13.1 and 13.2). The
patient’s physical examination can be supplemented with concurrent dialysis measures such as those indicating recirculation (when
needle placement is correctly spaced and placed) or other measures of reduced dialysis adequacy (eg, urea reduction ratio or Kt/V), in
the absence of other contributing factors.
Complications:
 Thrombotic flow–related complications or dysfunction: Complications specifically related to the risk of or occurrence of
thrombosis that leads to a clinically important reduction in intra-access flow that threatens the required access patency to achieve
prescribed dialysis and/or results in clinical signs and symptoms (eg, stenosis or thrombosis).
 Non–thrombotic flow–related complications or dysfunction: Such complications may or may not threaten flow or patency
but are associated with clinical signs and symptoms, eg, AV access aneurysms, steal syndrome.
 Infectious complications or dysfunction: Any infection involving the vascular access (intraluminal/access, extraluminal/
access, peri-access, ie, cannulation or entry site) that results in clinically important infectious signs and symptoms.
Contingency plan: The plan of remedial measures for the anticipated problems the chosen vascular access might have. The contingency
plan should be considered even before the vascular access is created or inserted.
Cumulative patency: A duration of time measuring intra-access patency that starts from the date of vascular access creation (AV
access) or insertion (central venous catheter) to the date of vascular access abandonment.
Diagnostic testing: Specialized testing that is prompted by some abnormality or other medical indication and that is undertaken to
diagnose the cause of the vascular access problem.
Dialysis usability: A dialysis access that can reliably and safely provide prescribed dialysis, per definition of mature fistula or graft.
Distal revascularization and interval ligation: A surgical procedure to reduce ischemia to the hand caused by steal syndrome.
Dysfunction: AV access or vascular access dysfunction has been replaced by 3 terms:
 Thrombotic flow–related complications or dysfunction
 Non–thrombotic flow–related complications or dysfunction
 Infectious complications or dysfunction
Note: Access dysfunction is a very general term that is not specific in its terminology with regard to etiology of dysfunction. For this reason, it has been
replaced with these three terms (see definition of complications).
ESKD (End-Stage Kidney Disease) Life-Plan: The individualized set of kidney replacement modalities (hemodialysis, peritoneal
dialysis, transplantation) required to sustain the life of a patient with ESKD that considers the patient’s current and anticipated medical
and life circumstances and preferences. The Life-Plan should be regularly re-evaluated given expected changes in a patient’s life
circumstances. See Rationale/Background section of Guideline 1 for further explanation and discussion about its special relevance for
dialysis access.
Exit site: The location on the skin through which the catheter exits the skin surface. See also insertion site.
Failure to mature: An AV access that, despite radiologic or surgical intervention (ie, endovascular or open procedural management),
cannot be used successfully for dialysis by 6 months after its creation.1
Fistula (plural, fistulae or fistulas): Autologous arteriovenous fistula, also referred to as native fistula.
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S11
 Brescia-Cimino (radiocephalic) fistula: An autologous fistula constructed between the radial artery and the cephalic vein at the
wrist.
 Endovascular fistula (or endoAVF): An autologous fistula created by endovascular techniques, originally described by anastomosis
of the proximal ulnar artery and proximal ulnar vein.
 Gracz fistula: An autologous fistula constructed between the proximal radial artery and a perforating branch of the cephalic or
median cubital vein below the elbow.
 Snuff-box fistula: An autologous fistula constructed between a branch of the radial artery and an adjacent vein in the anatomic
snuff box of the hand.
Fistula maturation: The process by which a fistula becomes suitable for providing prescribed dialysis.
 Unassisted fistula (or unassisted AVF): An arteriovenous fistula that matures and is usable for dialysis without the need for
endovascular or surgical interventions, such as angioplasty. A preplanned vessel superficialization is acceptable and not
considered an additional intervention.
Flow: The amount of blood flowing through a system.
 Qa: Intra-access blood flow
 Qb: Blood pump flow delivered to the dialyzer
Functional cumulative patency: Duration of time from mature fistula or graft to AV access abandonment (ie, from the first date the
AV access is able to provide prescribed dialysis consistently with 2 needles for more than two thirds of dialysis sessions within 4
consecutive weeks to the date of AV access abandonment).
Functional primary patency: The duration of time from mature fistula or graft to one of the following events (whichever comes
first): thrombosis or any intervention to facilitate, maintain, or re-establish patency (eg, angioplasty) (ie, from the first date the AV
access is able to provide prescribed dialysis consistently with 2 needles for more than two thirds of the dialysis sessions within 4
consecutive weeks to the date of one of the following events [whichever comes first]: thrombosis or any intervention to facilitate,
maintain, or re-establish patency [eg, angioplasty]).
Graft: A conduit of synthetic or biological material connecting artery to vein.
 Synthetic: Made of plastic polymers, such as polytetrafluoroethylene (PTFE) or polyurethane.
 Biological: Made of biological materials, such as bovine carotid artery, cryopreserved human femoral veins, biologically
engineered vessels, etc.
 Tapered: Grafts for which internal diameter varies from the arterial to the venous end.
 Untapered: Grafts with a uniform diameter, usually 6 mm.
Infiltration injury: Infiltration injury is vessel injury related to cannulation or the dialysis procedure and can be categorized as
follows:
 Minor cannulation injury: An injury that may result in bleeding infiltration and swelling that may be treated with conservative
measures such as ice and rest for 1 to 2 days; cannulation can be reattempted for the next dialysis session. The access should be
successfully recannulated with 2 needles in ≤7 days.2
Even a minor cannulation injury may require the use of a temporary
catheter.
 Major cannulation injury: An injury that results in significant bleeding infiltration and swelling that requires recovery for >7
days.3
 Severe cannulation injury: An injury that results in significant bleeding complications that requires one of the following: blood
transfusion, emergency department visit, hospitalization, or endovascular or surgical intervention.
Insertion site: The location at which the catheter enters the vein (eg, “The right internal jugular vein is the preferred insertion site”).
See also exit site.
Lesion, clinically significant: One that contributes to clinical signs and symptoms (see AV Access Monitoring Table 13.2) without
other cause, with or without a sustained change in measurements (eg, change in access flow [Qa] or venous pressures) in the dialysis
access circuit. Such a lesion is found during monitoring of vascular access (surveillance findings are supplementary).
Magnetic resonance angiography (MRA): A technique to visualize the arterial and venous systems using a radiologic contrast
material, usually gadolinium, as the imaging agent.
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Mature fistula: A mature fistula can be defined as physiologically mature or functionally mature.3-5
In these guidelines, a mature fistula
is one that can provide prescribed dialysis consistently with 2 needles for more than two thirds of dialysis sessions within 4
consecutive weeks. The criterion of two thirds is used to include studies referenced in these guidelines; however, it must be
emphasized that truly mature AV access should provide reliable prescribed dialysis most times, given expert cannulation and lack of
cannulation or other technical complications.
Mature graft: In these guidelines, a mature graft is one that can provide prescribed dialysis consistently with 2 needles for more than
two thirds of dialysis sessions within 4 consecutive weeks.1
The criterion of two thirds is used to include studies referenced in these
guidelines; however, it must be emphasized that truly mature AV access should provide reliable prescribed dialysis most times, given
expert cannulation and lack of cannulation or other technical complications.
Monitoring: See clinical monitoring.
Neointimal hyperplasia: The myoendothelial proliferation of cells and matrix that produces stenosis in AV accesses.
Operator: An operator can be a surgeon, nephrologist, radiologist, or other properly trained and skilled healthcare provider. An operator
is the individual who creates, revises, or removes the AV access or inserts, manipulates, or removes the central venous catheter.
Operator discretion: When the operator carefully considers both the patient’s individual circumstances and the operator’s own
clinical experience, skills, and expertise (ie, reasonable capabilities and limitations).
Patency: See cumulative patency, functional cumulative patency, functional primary patency, primary patency. Secondary patency can be a confusing term
and has the same definition as Cumulative Patency. KDOQI suggests using the term cumulative patency to help standardize vascular access
terminology.
Percutaneous transluminal angioplasty: The endoluminal repair of a lesion, usually with a balloon that can be inflated to pressures
up to 30 atmospheres.
Physical examination (of the vascular access): Inspection, palpation, and auscultation of the vascular access.
Primary failure: The terms primary failure, failure to mature, early failure, late failure, and mature fistula have been inconsistently defined in the
literature.1
These guidelines have attempted to avoid discussion of primary failure due to these inconsistencies; however, when they
appear, they are defined by the original study from which they are discussed.
Primary patency: A duration of time measuring intra-access patency that starts from the date of vascular access creation (AV access)
or insertion (central venous catheter) to the date of one of the following events (whichever one comes first): thrombosis or any
intervention to facilitate, maintain, or re-establish patency (eg, angioplasty).
Pseudoaneurysm: A collection of blood outside the vessel (walled off by surrounding tissue), communicating with the fistula or
prosthetic graft through a defect (eg, needle hole) in the wall.
Recirculation: The return of dialyzed blood to the systemic circulation without full equilibration.
 Cardiopulmonary recirculation: Resulting from the return of dialyzed blood without full equilibration with all systemic
venous return.
 Access recirculation: Resulting from the admixture of dialyzed blood with arterial access blood without equilibration with the
systemic arterial circulation. Occurs under conditions in which blood pump flow is greater than intra-access flow.
Steal syndrome: Compromised perfusion and ischemia of tissue after construction of an AV access due to diversion of arterial blood
flow into the AV access away from the peripheral system, leading to a range of signs and symptoms, such as mild numbness to severe
motor impairment or skin ulceration to gangrene necessitating major amputation.
Stenosis: A constriction or narrowing of a duct or passage; a stricture.
 Cephalic arch stenosis: A common site for stenosis of the cephalic vein; the location of narrowing occurs in the cephalic vein as
it arches over the shoulder in the region of the deltopectoral groove before the vein junction with the axillary vein.
Succession plan: The thoughtful planning for the next dialysis access (what it should be, location, appropriate timing of when it
should be created/inserted, by whom, etc) before the current vascular access is even created. The succession plan should be reevaluated
when there are changes in the patient’s medical or life circumstances and revisited before the current vascular access
fails. All such considerations take into account the patient’s ESKD Life-Plan, individual circumstances, and preferences.
Surveillance: The periodic evaluation of the vascular access by using device-based methods or tests that involve special instrumentation
beyond clinical examination and for which an abnormal test result suggests the presence of thrombotic flow–related
complications/dysfunction (defined under dysfunction). One example is attempting to detect stenosis by measurement of access
blood flow. Access blood flow (Qa) can be measured by a number of different techniques including estimation of flow by Doppler
ultrasound, dilution techniques such as ultrasound dilution, differential conductivity, glucose infusion, ionic dialysance, and timed
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S13
ultrafiltration methods or by magnetic resonance angiography (MRA). Other surveillance methods include static venous pressure.
(Dynamic venous pressure is considered monitoring, not surveillance.)
Tissue plasminogen activator (TPA): A natural (endogenous) lytic used to dissolve fibrin or nonorganized thrombus. rTPA is the
exogenous recombinant form used for vascular access intervention.
Transposition: The movement of a vein from its normal position by elevation and/or by lateral movement to bring the vein closer to
the skin to permit improved maturation and/or easier cannulation or use for dialysis.
Ultrasound: The use of ultrasonic waves for diagnostic or therapeutic purposes, specifically to image an internal body structure.
 Doppler ultrasound (DU): Ultrasound that uses the Doppler effect to measure movement or flow in the body, especially blood
flow.
 Duplex Doppler ultrasound: Combines Doppler and B-mode (grayscale) imaging to provide quantitative color velocity
assessment (AV access flow) as well as anatomic visualization of stenosis/abnormality.
Systolic velocity ratio (SVR): The ratio of velocity in an abnormal vessel relative to a normal vessel.
Urokinase: A natural lytic used to dissolve fibrin or nonorganized thrombus.
Vascular access coordinator (VAC): An individual knowledgeable in dialysis access who coordinates vascular access care of the
patient. This is achieved by patient and vascular access assessment, facilitating communication between the vascular access team
(VAT) members, organizing/managing required vascular access tests, treatments, and required follow-up vascular access–related
appointments. Often responsible for managing vascular access database and has a role in associated inputs, analysis, interpretation,
and outputs. Usually critically involved in quality improvement projects.
Vascular access team (VAT): Patient and group of professionals involved in management of vascular access (includes caregivers who
construct, cannulate, monitor, detect problems in, and repair vascular accesses). Caregivers include nephrologist, nephrology nurse,
patient care technician, nurse practitioner, physician assistant, interventionalist, surgeons, and vascular access coordinator (VAC).
S14 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Chronic Kidney Disease Nomenclature Used by KDOQI
Prognosis of Chronic Kidney Disease by Glomerular Filtration Rate and
Albuminuria Categories
Green: low risk (if no other markers of kidney disease, no chronic kidney disease [CKD]); Yellow: moderately increased
risk; Orange: high risk; Red, very high risk.
Figure reproduced from Inker et al6
based on the original image published in the Improving Global Outcomes KDIGO
CKD guideline7
; original image © 2012 KDIGO and is reproduced with permission of KDIGO.
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S15
FOREWORD
This third update of the KDOQI Clinical Practice
Guideline for Vascular Access represents a complete
revamping of the Vascular Access Guideline update that was
released in 2006. This comprehensive update was performed
due to the significant growth in the evidentiary database for
vascular access, which was thoroughly surveyed by the evidence
review team based at the University of Minnesota
in Minneapolis, Minnesota. A number of important randomized
clinical trials addressing vascular access for maintenance
hemodialysis have been performed since the
publication of the 2006 KDOQI clinical practice guideline for
vascular access. More than 4,600 articles were reviewed to
develop this guideline, for which 286 articles were included
in the evidence tables used to develop the 26 guideline sections,
their statements, and the research recommendations.
Hemodialysis access issues are managed by a number of
different medical professionals. Thus, the Work Group that
wrote this guideline is multidisciplinary, with members
representing not only clinic-based nephrologists but also
interventional nephrologists, radiologists, surgeons, and
vascular access nurses, including the past presidents of both
the American Society of Diagnostic and Interventional
Nephrology and the Vascular Access Society of the Americas.
An important new concept introduced in this Vascular
Access Guideline update is the End-Stage Kidney Disease
(ESKD) Life-Plan. This individualized and comprehensive
map for dialysis modalities and vascular access for the
lifetime of the patient is documented in this guideline and
will be supplemented by implementation tools that will be
developed by the NKF.
This document is the culmination of thousands of hours
of volunteer time by the guideline Work Group members
as well as by those health care professionals and patients
who participated in the internal and external reviewers of
this guideline. The NKF extends its deepest appreciation to
all of those volunteers who contributed their time and
effort in developing this guideline. Special gratitude is
expressed to Dr Charmaine E. Lok of the University of
Toronto, the Work Group chair, for her tireless efforts to
bring this document to fruition, as well as to the 2
guideline scope vice-chairs, Dr Surendra Shenoy of the
Washington University School of Medicine and Dr Alexander
S. Yevzlin of the University of Michigan, and to the
2 editorial committee members, Dr Thomas S. Huber of
the University of Florida and Dr Timmy Lee of the University
of Alabama. It is their commitment and dedication
to the KDOQI process that has made this guideline document
possible.
Michael V. Rocco, MD, MSCE
Chair, NKF KDOQI
© 2019 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.
0272-6386/$36.00
https://doi.org/10.1053/j.ajkd.2019.12.001
S16 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
INTRODUCTION
Rationale
Hemodialysis continues to be the single most prevalent
modality of kidney replacement therapy in the United
States.8
Longevity on dialysis is directly proportional to
the quality of dialysis, and that quality in turn depends
on the reliability and integrity of the access to the patient’s
vascular system. This crucial connection is known
as the hemodialysis vascular access. The ideal hemodialysis
vascular access is one that provides reliable, complicationfree
access to deliver prescribed dialysis and that is also
concurrently suitable for a given patient’s needs. The last
revision of the NKF KDOQI Clinical Practice Guidelines
for Vascular Access was completed in 2006. Since then,
improvements in the care of patients with ESKD, changes
in patient demographics, and increasing patient longevity
have resulted in a renewed interest in vascular access
management. There is a need to readdress some of the
practices previously considered to be best practices that
have evolved as a result of updated data derived from
clinical research and changing ESKD care delivery
patterns.
The 2019 Guideline represents a fresh approach to
vascular access care. Although the guideline statements are
grounded in rigorous and sophisticated evaluation and
integration of data accumulated over the last several decades,
the resulting guidance statements reflect the Work
Group’s thoughtful and practical application to support
multidisciplinary care providers in meeting the dialysis
access needs of individual patients. These guideline statements
emphasize a more patient-focused approach and
recommend development of an ESKD Life-Plan, taking
each patient’s needs and preferences into consideration
when choosing an access and planning up front for the
likely complications and remediations of the current access,
along with the transition plan to the next access.
Thus, the focus moves away from the prior Fistula First
approach and urges providers to think not only about what
access is first, but “what’s next” during the planning of the
first access. Indeed, the first access may be a peritoneal
dialysis (PD) catheter access, so the ESKD Life-Plan encourages
a comprehensive evaluation of the patient’s lifetime
with ESKD and kidney replacement therapy options.
This will have many benefits, including to help preserve
vessels needed for successful future AV access creation and
use and to avoid unnecessary procedures and complications.
To summarize, KDOQI has refocused on a P-L-A-N
for each patient: Patient Life-Plan first, followed by his or
her corresponding Access Needs (Figs 1.1-1.6).
Moreover, we did not update the previous guideline
statements number for number but, rather, used the new
and existing evidence to reframe our approach to the topic.
New or more rigorous evidence has reshaped some prior
recommendations. For example, there is a de-emphasis on
the need for AV access surveillance but a greater emphasis
on the need for improved training and application of
vascular access monitoring. We address the preparation for
and creation of vascular accesses, the care and management
of each type of vascular access, and the prevention and
treatment of complications.
These guideline statements are less prescriptive in targeting
the fine details within each of these areas, recognizing
differences in practice patterns but still emphasizing
the need for high-quality standards. As a result, we present
only 3 primary targets for use in tracking performance.
One target reinforces the idea that each patient has a
regularly updated Life-Plan designed with his/her goals in
mind to achieve the most suitable dialysis access type and
considers changes in circumstances. Other chosen targets
for each access type aim to limit the major known complications
associated with that access type (eg, an infection
rate target for central venous catheters). We chose to limit
the number of targets to reasonably enable and encourage
achievement. Our focus is on supporting the actions that
will lead to the ideal vascular access as defined earlier, such
as “reliable,” “complication-free . . . to deliver prescribed
dialysis,” and “concurrently suitable for a given patient’s
needs.”
Finally, we recognize the gaps in knowledge and evidence
in vascular access care and provide suggestions for
future research. We highlight the need for continual reevaluation
within each area of care and corresponding
section of the guideline, making room for new evidence
and innovations in dialysis access and its affiliated activities
and therapies.
This guideline is the result of 3 years of work, consisting
of a substantial literature review, months of evidence
analysis and discussion, and multidisciplinary
integration of the resulting data into practical guidance for
chronic kidney disease (CKD) and end-stage kidney disease
(ESKD) care providers. We see this guideline as a recalibration
and evolution of the previous recommendations.
We hope that it will be valuable to our colleagues, helpful
for policy makers, and influential in improving the lives of
those living with CKD/ESKD.
Methods
The KDOQI guideline development process began with
selection of the topic and refinement of the Guideline
Scope, followed by a comprehensive literature review of
the available evidence. The Guideline Scope was led by the
Chair and Vice Chairs of the Guideline Scope Committee
with refinement after input from the entire multidisciplinary
Work Group. The literature review and evidence
analysis for this update were independently carried out by
the University of Minnesota Evidence-Based Practice Center,
at the Minneapolis VA Center for Chronic Disease
Outcomes Research. Members of a multidisciplinary Work
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S17
Group were chosen by the Guideline Chair and Guideline
Scope Vice Chairs based on their content and methodology
expertise and representation of fields including nephrology
(adult and pediatric), nursing, vascular surgery, interventional
nephrology, interventional radiology, epidemiology,
and biostatistics. The analysis and quality of
evidence provided by the independent evidence review
team (ERT) was reviewed and discussed by this Work
Group using a formal GRADE Evidence to Decision
format.9,10
The Work Group, through use of standardized
work sheets, a series of regular conference calls, email
correspondence, and 2 in-person meetings, developed
guideline statements and accompanying strength of recommendations.
After statements were agreed upon,
guideline sections were drafted by individual members of
the Work Group. Once all sections were drafted, they were
re-reviewed by the entire multidisciplinary team via
weekly-monthly teleconferences until consensus was achieved.
If none was achieved, the statement went to a vote,
with majority vote being the resulting statement; these
have been identified in the guideline document. The
guideline Chair and 2 editorial committee members (TH
and TL) made editorial revisions to the text for flow and
comprehensiveness.
Literature Review and Evidence Analysis
Data Sources and Searches
The ERT searched bibliographic databases, including
MEDLINE and Embase via Ovid, and the Cochrane Library
to identify studies published from January 2000 through
October 2016. Search strategies are available in
Supplement 1. They supplemented bibliographic database
searches with citation searching of identified studies.
Study Selection
The ERT included trials and prospective observational
studies with parallel groups that compared vascular access
interventions and reported outcomes preselected for their
review. Relevant interventions included those related to
different vascular access types. They excluded studies
enrolling predominately (<75%) pediatric or acute kidney
injury participants, studies enrolling predominately
(<75%) participants with vascular accesses created before
2000, studies not reporting outcomes relevant to their
review, and studies not published in English.
Two investigators independently reviewed titles and
abstracts of search results to identify potentially eligible
references. Two investigators independently screened the
full text of those references to determine if they met inclusion
criteria. A third investigator resolved
discrepancies.
Data Extraction and Quality Assessment
One reviewer extracted population and comparison characteristics
from all eligible studies. Risk of bias was independently
assessed for each eligible study by 2
investigators using methods outlined by the Agency for
Healthcare Research and Quality.11
Risk of bias was
assessed as low, medium, or high based on selection of the
exposed and unexposed populations, similarity of surveillance
for the outcome, measurement of and adjustment
for prognostic imbalance, and attrition. Studies assessed as
low or medium risk of bias were included in their analyses.
Members of the ERT extracted data in a hierarchical
manner to efficiently capture the most relevant data and
avoid duplication of samples (when more than 1 study
used the same data set). If there was a randomized
controlled trial (RCT) for a comparison, they did not
extract data from observational studies, unless the
observational study reported a unique outcome. When a
comparison was addressed only with observational
studies, they identified and extracted data from large
registry studies first. If there were multiple studies using
the same database, such as the US Renal Data System
(USRDS) or same patient population and reporting the
same outcomes, they extracted only the study with the
most recent data. If studies reported data that were
included in the registry studies, they extracted data from
these studies only if they reported a different outcome
from registry studies. They did not extract data from
studies if their contribution to the total population
analyzed for that comparison was less than 3%. When
studies used multivariate analysis, they extracted the most
fully adjusted models and listed confounders adjusted for
in the evidence table.
Data Synthesis and Analysis
The ERT grouped studies by comparison and independently
analyzed statistical significance of the results. Heterogeneity
in study populations and methods prevented
data pooling. They assessed quality of evidence using
GRADE.12
Evidence quality was rated high, moderate, low,
or very low.
Development of Guideline Statements
The Work Group drafted clinical practice guideline statements
based on the evidence amassed by the ERT.
Some statements are similar to those of the previous
guidelines published in 200613
but have been reemphasized
or reinterpreted in light of new data. For
each of the guideline statements, the quality of the evidence
and the strength of the recommendations were
graded separately using the Grading of Recommendations
Assessment, Development, and Evaluation (GRADE)
approach criteria.9,14
The Work Group used an adapted
version of these scales using high to very low for quality of
the evidence and strong or conditional for the strength of the
recommendation. Recommendation strength includes
assessment of the statement’s potential clinical impact
(Tables A and B). The guideline statements were based on
a consensus within the Work Group that the strength of
the evidence amassed by the ERT was sufficient to make
Introduction
S18 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
definitive statements about appropriate clinical practice.
When the strength of the evidence was not sufficient to
make graded statements but the subject or intervention
was deemed important for inclusion, the Work Group
identified the statement as “There is inadequate evidence
for KDOQI to make a recommendation . . .”, and then
identified the important issue. It was believed important to
communicate to the community that the issue has been
identified but that further research is required. Finally,
there were many important topics that were excluded by
the ERT because they did not make the ERT search criteria
or criteria for analysis. Because of their importance, the
Work Group offered guideline statements based on the
best available evidence, independent of the ERT. Such
statements begin with “KDOQI considers it reasonable”
and are labeled Expert Opinion. Expert Opinion statements are
the consensus opinion of the Work Group based on best
available evidence and are ungraded. Phrasing and definitions
presented were also decided on by a formal, full
group process. The statements and definitions that
required voting included the classification and working
definition of vascular access complications, the wording of
Guideline 3.1, B on vascular access location order, the
wording of the Guideline 7 statement on routine preoperative
ultrasound, and strength of recommendation of the
Guideline 11 statement on AV access cannulation
technique.
Regarding all of the guideline statements, clinicians
should be aware that each patient and his/her circumstances
are unique and require careful thought and individualization;
thus, best clinical judgment must be used
with careful application of a guideline statement, which
may infrequently stray from the recommendations of the
Work Group to allow for optimal patient outcomes.
This guideline and supplementary files were put
through formal internal and external review processes.
Internal review took place in March 2019 and included
feedback from 14 individuals and groups, including the
NKF Scientific Advisory Board, American Society of Diagnostic
and Interventional Nephrology, and Vascular Access
Society of the Americas. Reviewers were asked to read each
recommendation and its supporting text; indicate whether
they agreed, disagreed, or partially agreed with each; and
provide comment if desired.
A public review period (May 2019) followed the
same format and received 50 responses. A link to all
documents was emailed to individuals who registered to
receive it, and NKF publicized the review through email
and social media channels. Changes and edits were made
to the manuscript following each review.
Internal Review
The NKF KDOQI process for internal and external reviews
is as follows:
 Once the guideline text is signed off by the Work Group
Chairs, recommendations are formatted and circulated to
KDOQI Leadership and the NKF Scientific Advisory Board
for review. Reviewers are asked to use an online form that
presents each recommendation, along with a box to
check agree, partially agree, or disagree and space for comment.
 At the discretion of the KDOQI Chair, select outside
experts and organizations may also be invited to
comment at this stage.
 Reviewer comments are collated by KDOQI staff and
sent to the Work Group for discussion and possible
edits.
 Individual Work Group members are assigned various
guideline sections and are asked to address reviewer
comments; to ensure a range of perspectives, each
guideline section is reviewed by a number of group
members. The entire Work Group then meets and discusses
the suggested edits or additions and comes to a
consensus.
 After Work Group edits, the guideline document is
distributed for public review.
External (Public) Review
 Throughout the later stages of guideline development, a
link to register for public review is posted to the NKF
guidelines web page.
 The document is sent to registered reviewers and publicized
to other individuals and groups with an interest
in the topic.
 Public reviewers are provided with a link to the online
form that presents each recommendation along with a box
tocheckagree,partially agree, or disagreeandspacefor comment.
 Reviewer comments are collated by KDOQI staff and
sent to the Work Group for discussion and possible
edits.
 Individual Work Group members are assigned various
guideline sections and are asked to address reviewer
comments; to ensure a range of perspectives, each
guideline section is reviewed by a number of group
members. The entire Work Group then meets and discusses
the suggested edits or additions and came to a
consensus.
 The Work Group Chairs coordinate the final rewriting
of the guideline document based on the public review
comments, after which the final manuscript is submitted
for publication in the American Journal of Kidney Diseases.
Introduction
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S19
Box 1. Grade for Strength of Recommendation
Evidence Base Grade
Implications
Patients Clinicians Policy
ERT derived Strong recommendation:
“We recommend”
Most people in your situation
would want the
recommended course of
action, and only a small
proportion would not.
Most patients should receive the
recommended course of action.
The recommendation can
be adopted as policy in
most situations.
ERT derived Conditional
recommendation/
suggestion:
“We suggest”
The majority of people in your
situation would want the
recommended course of action,
but many would not.
Different choices will be
appropriate for different
patients. Each patient needs
help to arrive at a
management decision
consistent with her or his
values and preferences.
The recommendation is
likely to require
substantial debate and
involvement of
stakeholders before
policy can be
determined.
ERT derived There is inadequate
evidence
The quality of the evidence was insufficient to make a suggestion or
recommendation (to support or not to support the intervention or topic)
but important enough to acknowledge as an area for future study
Work Group
derived
Ungraded
“KDOQI considers it
reasonable”
Ungraded recommendations are based on Work Group consensus and
the literaturea
not found through the formal ERT literature review.
Note: When a statement indicates, “There is inadequate evidence for KDOQI to make a recommendation,” the Work Group cannot make any
recommendation, suggestion, or other evidence-based guidance (in either direction) based on the very low, low, or inadequate quality of evidence
amassed by the ERT. The word “recommendation” is used for simplicity and encompasses both “recommendations” and “suggestions” (in either
direction). Also, expert opinion statements that allow for the use of “the clinician’s discretion and best clinical judgment” means that there is currently
no rigorous evidence to recommend a therapy, device, or strategy over another. The Work Group expects that ERT-derived evidence-based statements
will ultimately replace expert opinion-based statements once such rigorous evidence becomes available.
Abbreviations: ERT, evidence review team; KDOQI, Kidney Disease Outcomes Quality Initiative.
Adapted from Uhlig et al14
with permission of Elsevier; original version of table © 2006 International Society of Nephrology.
a
Many important topics, such as vein preservation, did not have accompanying studies that met the strict ERT search, retrieval, and analysis criteria
(above). However, if the Work Group believed the topic was important enough to be included in the Clinical Practice Guideline, statements were
made on these important topics with the Work Group’s best attempts to support the statements with the most relevant evidence available through
August 2018.
Box 2. Grade for Quality of Evidence
High quality of evidence. We are confident that the true effect lies close to that of the estimate of the effect.
Moderate quality of evidence. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different.
Low quality of evidence. The true effect may be substantially different from the estimate of the effect.
Very low quality of evidence. The estimate of effect is very uncertain and often will be far from the truth.
Introduction
S20 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
SUMMARY OF GUIDELINE STATEMENTS
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates “There is inadequate evidence for KDOQI
to make a recommendation,” the Work Group cannot make any recommendation,
suggestion, or other evidence-based guidance (in either direction) based
on the very low, low, or inadequate quality of evidence amassed by the ERT.
Note: Expert opinion statements that allow for the use of “the
clinician’s discretion and best clinical judgment” mean that there is
currently no rigorous evidence to recommend a therapy, device, or
strategy over another. The Work Group expects ERT-derived evidencebased
statements will ultimately replace expert opinion–based statements
once such rigorous evidence becomes available. The clinician’s
discretion carefully considers both the patient’s individual circumstances
and the clinician’s own clinical experience and expertise (ie,
reasonable capabilities and limitations).
Guideline 1. Patient First: ESKD Life-Plan
Statements: ESKD Life-Plan and Vascular Access Choice
1.1 KDOQI considers it reasonable that each patient with progressive CKD and/or with an eGFR 15-20 mL/min/1.73 m2
or
already on kidney replacement therapy should have an individualized ESKD Life-Plan that is regularly reviewed, updated,
and documented on their medical record. (Expert Opinion)
1.2 KDOQI considers it reasonable to conduct an annual review and update of each patient’s individualized ESKD Life-Plan,
together with their health care team. (Expert Opinion)
1.3 KDOQI considers it reasonable that, in addition to regular monitoring, a minimum quarterly overall review and update of
each patient’s vascular access functionality, complication risks, and potential future dialysis access options be done
together with their health care team. (Expert Opinion)
Guideline 2. Vascular Access Types
Statements: AV Access: Indications for Use
2.1 KDOQI considers it reasonable to have an AV access (AVF or AVG) in a patient requiring HD, when consistent with their
ESKD Life-Plan and overall goals of care. (Expert Opinion)
Note: See specific sections on incident and prevalent patients and the choice of AV access type and their appropriate locations.
Statements: Central Venous Catheters (CVC): Indications for Use
2.2 KDOQI considers it reasonable in valid clinical circumstances to use tunneled CVCs for short-term or long-term durations
for incident patients, as follows (Expert Opinion):
Short-term duration:
 AVF or AVG created but not ready for use and dialysis is required
 Acute transplant rejection or other complications requiring dialysis
 PD patient with complications that require time-limited peritoneal rest or resolution of complication (eg, pleural leak)
 Patient has a living donor transplant confirmed with an operation date in the near future (eg, < 90 days) but requires
dialysis
 AVF or AVG complication such as major infiltration injury or cellulitis that results in temporary nonuse until problem is
resolved
Note: In special, limited circumstances where temporary CVC is required to manage a vascular access complication (eg, <2 weeks), it may be
acceptable to use a nontunneled CVC.
Long-term or indefinite duration:
 Multiple prior failed AV accesses with no available options (see anatomic restrictions below)
 Valid patient preference whereby use of an AV access would severely limit QOL or achievement of life goals and after
the patient has been properly informed of patient-specific risks and benefits of other potential and reasonable access
options for that patient (if available)
 Limited life expectancy
 Absence of AV access creation options due to a combination of inflow artery and outflow vein problems (eg, severe
arterial occlusive disease, noncorrectable central venous outflow occlusion) or in infants/children with prohibitively
diminutive vessels
 Special medical circumstances
Statements: Vascular Access for Incident Patients
The statements below are in the context of the ESKD Life-Plan and associated Access Algorithms and their considerations, such as patient
comorbidities, circumstances, etc.
2.3 KDOQI suggests an AV access (AVF or AVG) in preference to a CVC in most incident and prevalent HD patients due to
the lower infection risk associated with AV access use. (Conditional Recommendation, Low Quality of Evidence)
2.4 KDOQI considers it reasonable that the choice of AV access (AVF or AVG) be based on the operator’s/clinician’s best
clinical judgment that considers the vessel characteristics, patient comorbidities, health circumstances, and patient
preference. (Expert Opinion)
Summary of Guideline Statements
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S21
2.5 KDOQI suggests that if sufficient time and patient circumstances are favorable for a mature, usable AVF, such a functioning
AVF is preferred to an AVG in incident HD patients due to fewer long-term vascular access events (eg, thrombosis,
loss of primary patency, interventions) associated with unassisted AVF use. (Conditional Recommendation, Low Quality of
Evidence)
Note: Patient circumstances refer to vessel characteristics, patient comorbidities, health circumstances, and patient preference.
Note: Unassisted AVF use refers to an AVF that matures and is used without the need for endovascular or surgical interventions, such as
angioplasty. A preplanned vessel superficialization is acceptable and not considered an additional intervention.
2.6 KDOQI suggests that most incident HD patients starting dialysis with a CVC should convert to either an AVF or AVG, if
possible, to reduce their risk of infection/bacteremia, infection-related hospitalizations, and adverse consequences.
(Conditional Recommendation, Very Low–Moderate Quality of Evidence)
2.7 There is inadequate evidence for KDOQI to make recommendations on choice of incident vascular access type based on
associations with all-cause hospitalizations or mortality.
2.8 There is inadequate evidence for KDOQI to make a recommendation on choice of AVF vs AVG for incident vascular access
based on associations with infections, all-cause hospitalizations, or patient mortality.
2.9 There is inadequate evidence for KDOQI to make a recommendation for incident HD patients using a CVC on converting to
an AV access (AVF or AVG) within the first year of dialysis initiation, solely to reduce their risk of mortality.
2.10 KDOQI considers it reasonable to use tunneled CVC in preference to nontunneled CVC due to the lower infection risk with
tunneled CVC. (Expert Opinion)
2.11 KDOQI considers it reasonable to use nontunneled internal jugular CVC only for temporary purposes for a limited time
period (<2 weeks or per individual facility policy) to limit infection risk. (Expert Opinion)
Statements: Vascular Access in Prevalent HD Patients
2.12 There is inadequate evidence for KDOQI to make a recommendation on the type of vascular access preferred in prevalent
HD patients based on vascular access outcomes, patient hospitalizations, or mortality.
2.13 KDOQI considers it reasonable that prevalent HD patients use an AV access (AVF or AVG) in preference to a CVC, if
possible, due to the association with lower vascular access–related events (eg, infection, thrombotic, and nonthrombotic
complications). (Expert Opinion)
2.14 KDOQI considers it reasonable that if clinical circumstances are favorable for a mature, usable AVF, such a functioning
AVF is preferred to AVG in prevalent HD patients. (Expert Opinion)
Note: Clinical circumstances refer to patient’s vessel characteristics, comorbidities, health circumstances, potential exposure time to CVC use,
and patient preference.
2.15 KDOQI considers it reasonable in valid clinical circumstances to use tunneled CVCs for short-term or long-term durations
for prevalent patients, as follows (Expert Opinion):
Short-term duration:
 AVF or AVG created but not ready for use and dialysis is required
 Acute transplant rejection or other complications requiring dialysis
 PD patient with complications that require time-limited peritoneal rest or resolution of complication (eg, pleural leak)
 Patienthasalivingdonortransplantconfirmedwithanoperationdateinthenearfuture(eg,<90days)butrequiresdialysis
 AVF or AVG complication such as major infiltration injury or cellulitis that results in temporary nonuse until problem
is resolved
Note: In special, limited circumstances where temporary CVC is required to manage a vascular access complication (eg, <2 weeks), it may be
acceptable to use a nontunneled CVC.
Long-term or indefinite duration:
 Multiple prior failed AV accesses with no available options (see anatomic restrictions below)
 Valid patient preference whereby use of an AV access would severely limit QOL or achievement of life goals and
after the patient has been properly informed of patient-specific risks and benefits of other potential and reasonable
access options for that patient (if available)
 Limited life expectancy
 Absence of AV access creation options due to a combination of inflow artery and outflow vein problems (eg, severe
arterial occlusive disease, noncorrectable central venous outflow occlusion) or in infants/children with
prohibitively diminutive vessels
 Special medical circumstances
Guideline 3. Vascular Access Locations
Statements: AV Access Locations
The statements below are in the context of the ESKD Life-Plan and associated Access Algorithms and their considerations (eg, feasible
anatomy, etc).
Note: See Guideline Statements 2.2 and 3.2 for CVC use and location; this section refers to AVF or AVG.
3.1 KDOQI considers it reasonable to choose the site (location) of the AV access (AVF or AVG) after careful consideration of the
patient’s ESKD Life-Plan (Figs 1.1-1.6), potentially following the below paths. (Expert Opinion) See Guideline Statement
3.2 for CVC locations:
A) A patient’s ESKD Life-Plan includes an anticipated long duration (eg, >1 year on HD):
 Forearm AVF (snuffbox or distal radiocephalic or transposed radiobasilic)
Summary of Guideline Statements
S22 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
 Forearm loop AVG or proximal forearm AVF (eg, proximal radiocephalic, proximal vessel, and perforator combinations)
or brachiocephalic, per operator discretion
 Brachiobasilic AVF or upper arm AVG, per operator discretion
B) A patient’s ESKD Life-Plan includes an anticipated limited duration (eg, <1 year) on HD:
 Forearm loop AVG or brachiocephalic AVF (with high likelihood of unassisted maturation)
 Upper arm AVG
C) A patient urgently starts HD without prior sufficient time to plan for and/or create an AV access and has an anticipated
limited duration (eg, <1 year) on HD:
 Early or standard cannulation loop AVG (forearm or upper arm location), or CVC, per operator discretion and patient’s
clinical needs
Note: The choice of upper extremity location of an AVG should be based on the operator’s discretion and best clinical judgment
considering the patient’s ESKD Life-Plan, due to inadequate evidence to demonstrate a difference between forearm versus upper arm
AVG patency or complication outcomes (including infections, hospitalizations, and mortality).
D) A patient urgently starts HD without prior sufficient time to plan for and/or create an AV access and has an anticipated
long duration (eg, >1 year) on HD:
 PD catheter, and follow above algorithm (A) if PD not a long-term option or
 Forearm early cannulation loop graft; when AVG fails, follow above algorithm (A) or
 CVC if high likelihood of rapid AVF maturation and usability success, then follow above algorithm (A)
E) All AV access options in the upper extremity have been exhausted and patient’s ESKD Life-Plan includes a long duration
(eg, >1 year) on HD, the following may be considered based on individual patient circumstances and operator’s best
clinical judgment and expertise:
 Lower extremity AVF or AVG or HeRO Graft (Merit Medical)
While a suggested stepwise approach to AV access site selection is provided (Figs 1.1-1.6), modification of the approach is encouraged as
necessary to consider the individual’s ESKD Life-Plan and circumstances, and follow the below key principles, given available suitable vessels:
 Distal first to proximal next approach
 Always preserve the integrity of vessels for future vascular access options
 Nondominant extremity in preference to dominant, only if choices are equivalent
Statements: CVC Locations
3.2 KDOQI considers it reasonable to choose the site (location) of the CVC after careful consideration of the patient’s ESKD LifePlan
as follows (Expert Opinion):
 Upper extremity before lower extremity, only if choices are equivalent
 There are valid reasons for CVC use (Guideline Statement 2.2) and its duration of use is expected to be limited (eg, <3
months):
 AV access is likely to be ready for use in near future—consider preferential use of tunneled cuffed CVC in opposite
extremity to anticipated AV access
 Transplant is anticipated in near future (ie, preserve iliac vessels)—consider preferential use of tunneled cuffed right IJ
catheter
Note: See below guidance for more details on CVC location.
 Some experts support that in urgent dialysis start situations, under limited use circumstances (eg, <1 month) and
transplant is not an option, use of a tunneled, cuffed femoral CVC is acceptable (unless contraindicated) until the AV
access or PD catheter can be quickly created and used. Use of the femoral vein preserves the upper extremity vessels for
future AV access creation.
Note: Contraindications to femoral vein CVC include femoral or iliac vessel pathology or prior surgery/reconstruction; hygienic reasons
(eg, chronic unresolved diarrhea), morbid obesity (BMI > 35 kg/m2
), or other difficult vein access.
 When there are valid reasons for CVC use (Guideline Statement 2.2) and duration of use is expected to be prolonged
(eg, >3 months) without anticipated use of AV access, CVC may be placed in the following locations in order of preference:
 Internal jugular
 External jugular
 Femoral
 Subclavian
 Lumbar
Note: In the absence of contraindications, prior pathology (eg, central stenosis) or intervention (eg, pacemaker) CVC insertion on the
right side is preferable to the left side due to more direct anatomy. 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.
Guideline 4. AV Access Types and Materials
Statements: Novel AV Access Types and Materials
4.1 KDOQI suggests that the choice of material for an AVG should be based on the nephrologist’s or operator’s discretion and
best clinical judgment since the current evidence does not demonstrate that one graft material or modification thereof is
Summary of Guideline Statements
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S23
associated with improved outcomes in terms of patency or complications. (Conditional Recommendation, Low Quality of
Evidence)
4.2 KDOQI considers it reasonable to use early cannulation grafts as a CVC-sparing strategy in appropriate patients, considering
their ESKD Life-Plan. (Expert Opinion)
Guideline 5. CVC Configuration and Materials
Statement: CVC Configuration and Materials
5.1 KDOQI suggests that the choice of tunneled HD CVC type and design be based on the clinician’s discretion and best clinical
judgment. (Conditional Recommendation, Low Quality of Evidence)
Guideline 6. Timing, Preparation, and Planning for Creation/Insertion of Dialysis Access
Statements: Education on ESKD Modalities and Dialysis Access
6.1 KDOQI considers it reasonable for adult and pediatric patients with an eGFR ≤30 mL/min/1.73 m2
(CKD G4) with progressive
decline in kidney function to be educated on all modalities of kidney replacement therapy (KRT) options,
including transplantation, so that timely referral can be made for the appropriate modality and creation of a functional
dialysis access, if necessary. (Expert Opinion)
Note: For pediatric patients, calculate eGFR by Schwartz formula.
6.2 KDOQI considers it reasonable for adult and pediatric patients with a kidney transplant with an eGFR ≤ 30 mL/min/1.73 m2
(CKD G4) with progressive decline in kidney function, to be educated on all modalities of KRT options, including potential
re-transplantation, so that timely referral can be made for the appropriate modality and creation of a functional dialysis
access, if necessary. A re-review of the patient’s ESKD Life-Plan should occur. (Expert Opinion)
Note: For pediatric patients, calculate eGFR by Schwartz formula.
6.3 KDOQI considers it reasonable for PD patients with complications refractory to therapy and/or with circumstances that
make PD less conducive than HD to be educated on all kidney transplant and HD options, so that timely referral can be
made for the appropriate modality preparation and creation of a functional dialysis access, if necessary. A re-review of the
patient’s ESKD Life-Plan should occur. (Expert Opinion)
Note: See Special Discussions.
6.4 KDOQI considers it reasonable and important to ensure that the predetermined dialysis access is usable to provide the
prescribed dialysis when the patient is ready to initiate the planned dialysis (eg, an AV access is mature and ready for
cannulation for HD). (Expert Opinion)
6.5 KDOQI considers it reasonable that in patients who have unplanned or urgent dialysis starts with a CVC, the ESKD Life-Plan
is established with a dialysis access plan within 30 days of dialysis start. (Expert Opinion)
Statements: Referral for AV Access
In some facilities, referral of the patient for assessment by the vascular access team/surgeon for appropriate dialysis access is a different
process than referral for the actual creation/insertion. However, for simplicity, the Guideline recommendations have been combined, keeping in
mind variable timeframes between assessment for and creation of vascular access.
Nondialysis CKD Patients
6.6 KDOQI considers it reasonable that in nondialysis CKD patients with progressive decline in kidney function, referral for
dialysis access assessment and subsequent creation should occur when eGFR is 15-20 mL/min/1.73 m2
. Earlier referral
should occur in patients with unstable and/or rapid rates of eGFR decline (eg, >10 mL/min/year). (Expert Opinion)
Note: Nondialysis CKD patients include those with a failing transplant.
Hemodialysis Patients
6.7 KDOQI considers it reasonable that in HD patients with recurrent vascular access problems, prompt referral for assessment
and creation of a new AV access should be made to allow adequate time for specialist consult and follow-up, as well as
possible AV access failure and correction, and should consider individual patient circumstances and competing risk of
death. (Expert Opinion)
Note: Recurrent vascular access problems include recurrent need for CVC use and/or ≥3 corrective interventions/6 months.
When PD Is the Modality of Choice:
6.8 KDOQI considers it reasonable and ideal to place a PD catheter at least 2 weeks before the anticipated need of the PD
treatments. (Expert Opinion)
6.9 KDOQI considers it reasonable for an urgent PD catheter to be placed for immediate PD as necessary under the direction
and care of experienced personnel in conducive environments. (Expert Opinion)
Statement: Vessel Preservation
6.10 KDOQI considers it reasonable to protect all central and peripheral arteries and veins from damage whenever possible,
including the avoidance of peripherally inserted catheters and unnecessary venipunctures, for patients on dialysis or with
CKD where dialysis access is expected in the future (CKD G3-G5). (Expert Opinion)
Note: Other scenarios where vessel (artery or vein) damage may occur that should be avoided include (1) radial artery access for coronary
interventions and (2) venous cardiovascular implantable electronic devices; alternatives such as epicardial/leadless pacing should be
considered whenever possible.
Summary of Guideline Statements
S24 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Statements: Multidisciplinary Team Approach
6.11 KDOQI considers it reasonable to educate on, coordinate, and manage all aspects of dialysis access using a multidisciplinary
team within the resource capacities and feasibilities of each facility. (Expert Opinion)
6.12 There is inadequate evidence for KDOQI to make a recommendation on the use of a multidisciplinary team to reduce the
rate of CVC use or increase the use of AVF.
Guideline 7. Patient and Vessel Examinations: Prepratory Considerations
Statements: Patient Clinical Examination
7.1 KDOQI recommends that a physical examination focused on vascular anatomy be the basis for the initial assessment and
planning of vascular access creation. (Conditional Recommendation, Very Low Quality of Evidence)
7.2 KDOQI considers it reasonable to have greater emphasis on and more training in preoperative clinical examination to
assess patients and their vessels to determine the type and location of their vascular access. (Expert Opinion)
Statements: Vessel Mapping for Vascular Access
7.3 KDOQI suggests selective preoperative ultrasound in patients at high risk of AV access failure (Table 7.2) rather than routine
vascular mapping in all patients. (Conditional Recommendation, Low Quality of Evidence)
7.4 KDOQI considers it reasonable to use various imaging studies as needed to evaluate the suitability of vessels for AV access
creation, such as ultrasonography for peripheral vessels (including intraoperative ultrasound) and venography for suspected
central vein occlusion, while considering the patient’s clinical circumstances and residual kidney function. (Expert Opinion)
Statements: Optimal Vessel Size for Artery and Vein of AV Access Creation
7.5 KDOQI considers it reasonable that while there is no minimum-diameter threshold to create an AVF, arteries and veins of <2
mm in diameter should undergo careful evaluation for feasibility and quality to create a functioning AVF. (Expert Opinion)
7.6 KDOQI considers it reasonable to evaluate multiple characteristics of vessel quality for AVF creation (size, distensibility,
flow, etc). (Expert Opinion)
Guideline 8. AV Access Creation
Statements: Pre-Creation Infection Prevention
8.1 KDOQI considers it reasonable to conduct a careful history and physical exam by the operator and managing team prior to
AV access creation to identify infection risks that should first be managed before proceeding with AV access creation (eg,
dental infection, osteomyelitis, etc). (Expert Opinion)
8.2 KDOQI suggests that the choice of anesthesia for AVF creation should be based on the operator’s discretion and best
clinical judgment, as current evidence shows no difference between regional block or local anesthesia in terms of AVF
usability, patency, interventions, or patient experience. (Conditional Recommendation, Low-Moderate Level of Evidence)
Statement: AV Access Anastomotic Configuration and Apposition Methods
8.3 KDOQI considers it reasonable that the choice of anastomotic configuration and apposition method (eg, vascular clips,
sutures) for AVF creation be based on the operator’s discretion and best clinical judgment, as there is insufficient evidence
to prefer one configuration or apposition method over another. (Expert Opinion)
Statement: AV Access Anastomotic Suture Technique
8.4 KDOQI considers it reasonable that the choice of suture technique for AV access creation should be based on the operator’s
discretion and best clinical judgment, as there is insufficient evidence that any anastomotic suture technique is advantageous
in terms of AV access patency or complications. (Expert Opinion)
Statements: Use of Operator-Assisted Maneuvers for AV Access Maturation
8.5 KDOQI does not suggest the use of allogenic endothelial implants to improve AVF maturation, patency, or clinical usability
or to improve AVG graft patency or reduce thrombosis. (Conditional Recommendation, Very Low Quality of Evidence)
8.6 KDOQI does not suggest the use of pancreatic elastase to improve the patency and clinical use of AVF or AVG. (Conditional
Recommendation, Moderate Quality of Evidence)
8.7 KDOQI considers it reasonable to have a careful individualized approach to operator-enhanced (surgical or endovascular)
maneuvers during AV access creation to facilitate AV access maturation, based on the operator’s best clinical judgment and
expertise. (Expert Opinion)
Guideline 9. CVC Insertion
Statements: Techniques and Other Considerations for Placement
9.1 KDOQI recommends the use of image-guided CVC insertions to improve success of insertions. (Conditional Recommendation,
Moderate Quality of Evidence)
9.2 KDOQI considers it reasonable that if fluoroscopy is not used to insert a tunnelled CVC, alternative imaging is used to
ensure that the CVC tip has been correctly placed. (Expert Opinion)
Summary of Guideline Statements
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Guideline 10. Post–AV Access Creation/CVC Insertion Considerations
Statement: AV Access Early Postoperative Considerations (0-30 Days)—Early AV Access Complications
10.1 KDOQI considers it reasonable for AV access (AVF and AVG) to be evaluated by a surgeon/operator for postoperative
complications within 2 weeks and for an appropriate member of the vascular access team to evaluate for AVF maturation
by 4-6 weeks after AV access creation and refer for further investigation if not maturing as expected. (Expert Opinion)
Note: Ideally, the surgeon/operator evaluating for complications would be the same individual who created the AV access.
Statements: Postoperative AV Access Maturation
Patient Enhanced
10.2 There is inadequate evidence for KDOQI to make a recommendation on the use of upper extremity exercise to facilitate
postoperative AVF maturation.
10.3 KDOQI recommends the use of whole arm rather than finger exercise, if exercise is used to facilitate AVF maturation.
(Conditional Recommendation, Moderate-High Quality of Evidence)
Pharmacologic Intervention
10.4 KDOQI does not suggest the use of heparin as an adjuvant therapy in the perioperative period to improve primary patency
or initial use of AV access (AVF or AVG). (Conditional Recommendation, Low Quality of Evidence).
10.5 KDOQI does not suggest the use of adjuvant clopidogrel monotherapy initiation in the perioperative period to improve AVF
maturation and reduce the likelihood of primary failure. (Conditional Recommendation, Low Quality of Evidence)
10.6 KDOQI does not suggest the use of glyceryl-trinitrate to enhance AVF maturation. (Conditional Recommendation, Low
Quality of Evidence)
10.7 KDOQI does not suggest the use of cholecalciferol to enhance AVF maturation. (Conditional Recommendation, Moderate
Quality of Evidence)
10.8 There is inadequate evidence for KDOQI to make a recommendation on the use of clopidogrel-prostacyclin (iloprost) for
AVF usability or patency.
Endovascular and Surgical Intervention
10.9 There is inadequate evidence for KDOQI to make a recommendation on the preferred use of surgical or endovascular
techniques for postoperative maturation. It is reasonable to consider a careful individualized approach to using either
surgical techniques or endovascular techniques when needing to intervene on an AV access to enhance maturation
postoperatively.
Statements: Timing of CVC Removal
Noncuffed, Nontunneled Catheters (NT-CVC)
10.10 KDOQI considers it reasonable to limit the use of temporary, noncuffed, nontunneled dialysis catheters to a maximum of
2 weeks due to increased risk of infection, and this should be considered only in patients in need of emergent access.
(Expert Opinion)
Cuffed, Tunneled CVC
10.11 KDOQI considers it reasonable that in HD patients for whom a cuffed, tunneled CVC is the most appropriate permanent
dialysis access, there is no maximum time limit to CVC use, but regular evaluation is required to determine if the CVC
remains the most appropriate dialysis access. (Expert Opinion)
Note: Appropriate uses of a cuffed, tunneled CVC for chronic hemodialysis include the following:
(1) All other AV access options have been exhausted (after thorough multidisciplinary evaluation)
(2) Temporary switch from another modality (eg, PD, due to PD-related complications such as pleural leak, transplant–acute rejection,
etc), but the patient is expected to return to that modality after the complication is adequately resolved
(3) Awaiting live-donor kidney transplant with established surgical date (<90 days)
(4) Very limited life expectancy (eg, <6-12 months)
(5) Clinical conditions that would worsen with AV access (eg, HF with EF <15%, nontreatable skin lesions where cannulation/
scratching significantly increases infection or rupture risk, etc)
(6) Patient choice after proper informed consent (eg, competent, >85-year-old elderly woman with high risk of AV access failure, needle
phobia, and unknown life expectancy)
Note: The above points regarding appropriate use of CVC are discussed in Guideline Statement 2.2
Guideline 11. Vascular Access Use
Statement: Vascular Access General Monitoring
11.1 KDOQI considers it reasonable to assess or check the vascular access and surrounding area by physical exam prior to
every cannulation (if AV access) or connection (if CVC) for potential complications. (Expert Opinion)
Summary of Guideline Statements
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Statements: AV Access Cannulation
Please review Guideline Statement 11.1.
11.2 KDOQI recommends rope ladder cannulation as the preferred cannulation technique for AVFs. (Conditional Recommendation,
Moderate Quality of Evidence)
11.3 KDOQI considers it reasonable to limit AV access buttonhole cannulation only to special circumstances given the associated
increased risks of infection and related adverse consequences. (Expert Opinion)
11.4 KDOQI considers it reasonable to avoid buttonhole cannulation in synthetic PTFE grafts due to potential serious consequences.
(Expert Opinion)
11.5 KDOQI suggests that when select buttonhole cannulation is performed, the use of buttonhole cannulation devices to
facilitate cannulation should be at the discretion and expertise of the cannulator. (Conditional Recommendation, Low
Quality of Evidence)
11.6 KDOQI considers it reasonable to use skilled cannulators with established high rates of cannulation success to perform
initial AV access cannulations on patients to help avoid primary infiltration injury of the AV access. (Expert Opinion)
11.7 KDOQI considers it reasonable to have structured training and supervision of dialysis technicians and nurses before and
during their initial cannulation attempts, and regular training updates to maintain cannulation competency. (Expert
Opinion)
11.8 KDOQI considers it reasonable to support and educate eligible patients on self-cannulation of their AV access (AVF or
AVG). (Expert Opinion)
Note: To be clear, any consideration of buttonhole cannulation refers only to AVF and certain AVG materials. AVG made of PTFE should not be
accessed by buttonhole cannulation, due to risks of “one-siteitis” and its serious consequences.
Note: See Guideline Statement 12.2 for use of ultrasound for AV access cannulation.
Statements: CVC System Connect and Disconnect Procedure Considerations
Please review Guideline Statement 11.1.
11.9 KDOQI suggests the use of a catheter care protocol for exit site and hub care to reduce catheter-related bloodstream
infections and treatment of catheter dysfunction. (Strong Recommendation, Moderate Quality of Evidence)
11.10 KDOQI considers it reasonable, in addition to correct hand hygiene/washing, to use aseptic technique and masks for
patients and staff performing catheter connection and disconnection procedures. (Expert Opinion)
11.11 KDOQI considers it reasonable to cleanse the catheter hub when connecting and disconnecting the catheter with a
chlorhexidine based solution. If chlorhexidine is contraindicated (eg, sensitivity, allergy), povidone-iodine solution
(preferably with alcohol) is a reasonable substitute and should be used. (Expert Opinion)
11.12 KDOQI considers it reasonable at the time of catheter dressing change to cleanse the skin surrounding the catheter exit
site with a chlorhexidine based solution. If chlorhexidine is contraindicated (eg, sensitivity, allergy), povidone-iodine
solution (preferably with alcohol) is a reasonable substitute and should be used. (Expert Opinion)
11.13 There is inadequate evidence for KDOQI to make a recommendation on the specific chlorhexidine formulation to use for
infection prophylaxis, and this should be based on the clinician’s best clinical judgment and local practical
considerations.
11.14 There is inadequate evidence to demonstrate a difference in catheter-related infections with the use of transparent film
dressing compared with nontransparent dressing; thus, the choice of catheter dressing material should be based on the
clinician’s discretion that considers the patient’s circumstances and uses best clinical judgment.
11.15 KDOQI considers it reasonable to use a topical antiseptic or antibiotic barrier at the catheter exit site in addition to
cleansing until the exit site is healed to reduce the risk of catheter-related infection. (Expert Opinion)
11.16 There is inadequate evidence to demonstrate a difference in catheter-related infections between the use of various
antiseptic or antibiotic topical exit site barriers; thus, the choice of topical exit site barrier should be based on the clinician’s
discretion and best clinical judgment.
11.17 KDOQI considers it reasonable to follow these catheter care practices (Expert Opinion):
 The frequency of catheter dressing change should be based on the clinician’s discretion and best clinical judgment,
with a minimum of once weekly
 Catheter dressings should be protected against wet and dirty environments, particularly when the exit site is not yet
fully healed (eg, avoid swimming and showering)
Note: See Guideline Statements 21.2 and 21.3 for statements on CVC connectors to prevent CVC dysfunction or bacteremia and Guideline
Statements 24.3-24.5 for statements on intraluminal strategies for the prophylaxis of CVC-related infections.
Guideline 12. AV Access Cannulation Complications
Statements: AV Access Cannulation Complications
12.1 KDOQI considers the following therapeutic interventions for cannulation injury reasonable to follow:
 Any size infiltration: apply ice for a minimum of 10 minutes and refrain from maximizing the blood pump speed. (Expert
Opinion)
 If the infiltration is moderate, the needle should be withdrawn and manual pressure held over the infiltration site.
(Expert Opinion)
 If the infiltration is significantly large, in addition to the above, a decision on the necessity for dialysis that day is
required—if dialysis is required, a site proximal to the infiltration injury should be cannulated; if this is not possible,
reattempt at the area of injury should not proceed until manual pressure and ice is applied for 30 minutes. (Expert
Opinion)
Summary of Guideline Statements
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 If a hematoma develops, close assessment of the site, the AV access, and the adjacent extremity should be made,
including measurement of swelling, assessment of the presence of flow in the AV access both proximal and distal to the
hematoma, and circulation to the associated extremity. (Expert Opinion)
12.2 KDOQI considers it reasonable to use ultrasound to help determine direction of flow and proper needle placement in the
AV access of select patients as needed and performed by trained operators, to prevent cannulation complications. (Expert
Opinion)
Guideline 13. AV Access Flow Dysfunction—Monitoring/Surveillance
Note: “AV access flow dysfunction” refers to clinically significant abnormalities in AV access (AVF or AVG) flow or patency due to underlying
stenosis, thrombosis, or related pathology. This is in distinction to other types of AV access complications.
Statements: Appropriate Use of Monitoring/Surveillance for AV Access Flow Dysfunction
Physical Examination (Monitoring)
13.1 KDOQI recommends regular physical examination or check of the AVF, by a knowledgeable and experienced health
practitioner, to detect clinical indicators of flow dysfunction of the AVF. (Conditional/Strong Recommendation, Moderate
Quality of Evidence)
See Table 13.2 for clinical indicators.
13.2 KDOQI recommends regular physical examination or check of the AVG, by a knowledgeable and experienced health
practitioner, to detect clinical indicators of flow dysfunction of the AVG. (Conditional/Strong Recommendation, Moderate
Quality of Evidence)
See Table 13.2 for clinical indicators.
13.3 KDOQI considers it reasonable for nephrology trainees and health practitioners involved with clinical HD patient care to be
properly trained in physical examination of the AV access to monitor for and detect AV access flow dysfunction. (Expert
Opinion)
Surveillance to Facilitate Patency
13.4 There is inadequate evidence for KDOQI to make a recommendation on routine AVF surveillance by measuring access
blood flow, pressure monitoring, or imaging for stenosis, that is additional to routine clinical monitoring, to improve
access patency.
Note: In other words, monitoring of vascular access is primary, while surveillance findings are supplementary, and action should not be based
solely on surveillance findings.
13.5 KDOQI does not suggest routine AVG surveillance by measuring access blood flow, pressure monitoring, or imaging for
stenosis, that is additional to regular clinical monitoring, to improve AVG patency. (Conditional Recommendation, Low
Quality of Evidence)
Note: In other words, monitoring of vascular access is primary, while surveillance findings are supplementary, and action should not be based
solely on surveillance findings.
Investigation of Abnormalities Detected by Clinical Monitoring
Please refer to Guideline Statements 15.1-15.3.
Statements: Surveillance and Pre-emptive Intervention for AV Access Stenosis Not Associated With Clinical Indicators
Endovascular Intervention to Improve Patency
13.6 KDOQI does not recommend pre-emptive angioplasty of AVFs with stenosis, not associated with clinical indicators, to
improve access patency. (Conditional Recommendation, Moderate Quality of Evidence)
13.7 KDOQI does not recommend pre-emptive angioplasty of AVGs with stenosis, not associated with clinical indicators, to
improve access patency. (Conditional Recommendation, Moderate Quality of Evidence)
Surgical Intervention to Improve Patency
13.8 There is inadequate evidence for KDOQI to make a recommendation on pre-emptive surgical interventions in AVFs with
stenosis, not associated with clinical indicators, to improve access patency.
Statement: Pre-emptive Intervention for AV Access Stenosis Associated With Clinical Indicators
13.9 KDOQI considers it reasonable for patients with consistently persistent clinical indicators and underlying AV access stenosis
to undergo pre-emptive angioplasty of their AV access to reduce the risk of thrombosis and AV access loss. (Expert
Opinion)
Guideline 14. AV Access Flow Dysfunction—Prevention
Statements: Noninvasive Primary and Secondary Prevention of AV Access Flow Dysfunction
Note: “AV access flow dysfunction” refers to clinically significant abnormalities in AV access (AVF or AVG) flow or patency due to underlying
stenosis, thrombosis, or related pathology. This is in distinction to other types of AV access complications.
Summary of Guideline Statements
S28 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Fistulas
14.1 KDOQI suggests that the use of adjuvant far-infrared therapy to improve AVF primary patency be based on individual
circumstances, feasibility, and the clinician’s best judgment and expertise. (Conditional Recommendation, Moderate
Quality of Evidence)
14.2 KDOQI does not suggest the routine use of fish oil or aspirin to prevent AVF flow dysfunction. (Conditional Recommendation,
Low-Moderate Quality of Evidence)
14.3 There is inadequate evidence for KDOQI to make a recommendation on the use of simvastatin and ezetimibe to reduce
AVF interventions or thrombosis.
14.4 There is inadequate evidence for KDOQI to make a recommendation on the use of clopidogrel-prostacyclin to improve AVF
primary failure.
Grafts
14.5 KDOQI suggests careful consideration of potential individual patient benefits, risks, and circumstances prior to the use of
combination dipyridamole (200 mg) and aspirin (25 mg) twice daily to improve AVG primary unassisted patency. (Conditional
Recommendation, High Quality of Evidence)
14.6 KDOQI suggests the use of oral fish oil supplementation, in patients with newly created AV grafts, to reduce patient
morbidity (ie, reduce frequency of thrombosis and related corrective interventions). (Conditional Recommendation,
Moderate Quality of Evidence)
14.7 There is inadequate evidence for KDOQI to make a recommendation on the use of oral fish oil supplementation to prolong
AVG cumulative patency.
14.8 There is inadequate evidence for KDOQI to make a recommendation on the use of simvastatin and ezetimibe for reducing
AVG interventions and thrombosis.
Guideline 15. AV Access Flow Dysfunction—Confirmation and Treatment
Statements: Radiographic Confirmation of Clinically Significant AV Access Lesion
15.1 KDOQI considers it reasonable that when clinical monitoring suspects clinically significant AV access lesion (eg, stenosis),
further timely and confirmatory evaluation should proceed, including imaging of the dialysis access circuit. (Expert Opinion)
Notes:
 A clinically significant lesion is one that contributes to clinical signs and symptoms (see AV Access Monitoring, Table 13.2) without
other cause (with or without a change in surveillance measurements, such as change in blood flow [Qa] or venous pressures).
 Dialysis access circuit is defined as the continuum from the heart and the arterial inflow through the AV access to the venous outflow
back to the heart.
 The timeframe, choice, and extent of imaging studies for further evaluation are dependent on local resources and the severity of
findings on clinical monitoring; a timeframe of less than 2 weeks was deemed reasonable by the KDOQI Work Group.
15.2 KDOQI considers it reasonable to use the smallest volume of iodinated contrast or non-iodinated contrast agents (eg, CO2
gas) by operators knowledgeable in their uses, contraindications, and risks to obtain the best possible image in all patients
with CKD to preserve residual kidney function. (Expert Opinion)
15.3 KDOQI considers it reasonable that when further confirmatory imaging studies reveal a culprit lesion responsible for
clinical signs and symptoms, the clinically significant lesion is promptly treated. (Expert Opinion)
Note: A clinically significant lesion is one that contributes to clinical signs and symptoms (see AV Access Monitoring, Table 13.2) without other
cause (with or without a change in surveillance measurements, such as change in blood flow [Qa] or venous pressures).
Statement: General Treatment of Clinically Significant Stenosis or Thrombosed AV Access
15.4 KDOQI considers it reasonable to use a careful individualized approach to the treatment of failing or thrombosed AVF and
AVG (surgical or endovascular), based on the operator’s best clinical judgment and expertise and considering the patient’s
ESKD Life-Plan. (Expert Opinion)
Note: Consider both the patient’s individual circumstances and the operator’s clinical experience and expertise (ie, reasonable capabilities and
limitations); preferably discussed and agreed on by the team managing the patient’s vascular access, including but not limited to the patient
and one or more of the following: nephrologist, interventionalist, surgeon, vascular access coordinator, cannulators (nurse or technician).
Statements: Treatment of Clinically Significant AV Access Stenosis
Angioplasty
15.5 KDOQI considers it reasonable to use balloon angioplasty (with high pressure as needed) as primary treatment of AVF and
AVG stenotic lesions that are both clinically and angiographically significant. (Expert Opinion)
Note: Angiographically present stenosis without accompanying clinical signs and symptoms is inadequate to treat/intervene upon.
15.6 There is inadequate evidence for KDOQI to make a recommendation regarding the use of specialized balloons (drugcoated
or cutting) versus standard high-pressure balloons in the primary treatment of AVF and AVG stenosis.
15.7 There is inadequate evidence for KDOQI to make a recommendation regarding the optimal duration of balloon inflation
time during angioplasty to improve intervention primary patency in the treatment of AVF or AVG stenosis.
15.8 KDOQI considers it reasonable that a careful patient-individualized approach to the choice of balloon type for angioplasty
of clinically significant AVF and AVG stenosis be based on the operator’s best clinical judgment and expertise. (Expert
Opinion)
Summary of Guideline Statements
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Stents
15.9 KDOQI suggests the appropriate use of self-expanding stent-grafts in preference to angioplasty alone to treat clinically
significant graft-vein anastomotic stenosis in AVG when the goal is overall better 6-month postintervention outcomes
after carefully considering the patient’s ESKD Life-Plan. (Conditional Recommendation, Moderate Quality of Evidence)
Note: Appropriate use avoids cannulation segments.
Note: Overall better 6-month outcomes refer to reduced recurrent AVG restenosis ± improved patency.
15.10 KDOQI considers it reasonable to first consider the consequences of placement of a stent-graft on future AV access
options according to the patient’s ESKD Life-Plan, with consultation with the vascular access team if necessary, prior to
its placement. (Expert Opinion)
15.11 KDOQI suggests that the use of an appropriately placed stent-graft is preferred to angioplasty alone for the treatment of
in-stent restenosis in AVG and AVF for overall better 6-month postintervention outcomes. (Conditional Recommendation,
Moderate Quality of Evidence)
Note: Appropriate use avoids cannulation segments.
Note: Overall better 6-month outcomes refer to reduced recurrent AVG and AVF restenosis ± improved patency.
15.12 KDOQI considers it reasonable to avoid the use of bare metal stents for the treatment of clinically and/or angiographically
significant AVG and AVF stenotic lesions. (Expert Opinion)
Statements: Treatment of Thrombosed AV Access
15.13 KDOQI considers it reasonable that management of each episode of AV access thrombosis is at the operator’s/clinician’s
best judgement and discretion, and involves the consideration of the patient’s dialysis access Succession Plan that is
consistent with the ESKD Life-Plan, given the compromised AV access patency after either endovascular or surgical
treatment. (Expert Opinion)
Note: Operator’s/clinician’s discretion carefully considers both the patient’s individual circumstances and the operator’s/clinician’s own clinical
experience and expertise (ie, reasonable capabilities and limitations). The Succession Plan is a critical component of the P-L-A-N (see
Monitoring and Evaluation discussion in Guideline Statement 1).
15.14 KDOQI considers it reasonable to surgically treat a failing AV access in the following circumstances: (1) endovascular
treatment failures, (2) clinically significant lesions not amenable to endovascular treatment, and (3) situations in which
the surgical outcomes are deemed markedly better. (Expert Opinion)
Note: Situations when surgical outcomes are anticipated to be better than alternative options should be first discussed and agreed upon by the
team managing the patient’s vascular access, including but not limited to the patient and one or more of the following: nephrologist,
interventionalist, surgeon, vascular access coordinator, and cannulation expert, if possible.
Guideline 16. AV Access Infection
Statements: AV Access Infections
Monitoring and Prevention
16.1 KDOQI considers it reasonable to educate the patient on washing the access arm using antiseptic to clean the skin prior to
every cannulation. (Expert Opinion)
16.2 KDOQI considers it reasonable to check the vascular access and surrounding area prior to every cannulation for signs and
symptoms of infection. (Expert Opinion)
Note: This check should be done by patient and cannulator (if patient does not self-cannulate).
Special considerations from Guideline Statements 11.2, 11.3, and 11.7 are relevant to this section.
Diagnosis
16.3 KDOQI considers it reasonable to use radiologic imaging to help confirm the diagnosis of AV access infection; however,
physical examination remains the hallmark for assessing for infection. (Expert Opinion)
Note: Radiologic imaging includes duplex ultrasound, ± CT scan, PET, and nuclear medicine scans (eg, indium scan).
Note: Signs of infection include erythema, skin breakdown, purulent discharge, and presence of exposed graft.
16.4 KDOQI considers it reasonable to investigate and closely monitor for metastatic complications (eg, endocarditis, spinal
abscesses, septic arthritis) in patients with buttonhole infection from particularly dangerous organisms such as S aureus,
Gram-negative bacteria, and fungal organisms. (Expert Opinion)
Note: Investigations include 2D echocardiography, MRI, joint aspirate, and other, as appropriate.
Treatment
16.5 KDOQI considers it reasonable to obtain cultures and sensitivities of the blood and any available infected AV access
vessel/material, surrounding tissue, or drainage prior to initiating antibiotic therapy. (Expert Opinion)
16.6 KDOQI considers it reasonable for infected AV access the rapid initiation of empiric broad-spectrum antibiotics and timely
referral to a surgeon knowledgeable in the management of vascular access complications. (Expert Opinion)
16.7 KDOQI considers it reasonable to have strict follow-up of culture results with the appropriate change in antibiotics based
on organism sensitivities, with antibiotic duration according to extent of vascular access infection and surgical intervention.
(Expert Opinion)
16.8 KDOQI considers it reasonable that the specific surgical treatment for AV access infections (with concurrent antibiotics)
should be based on the patient’s individual circumstances considering the extent of infection, offending organism, and
future vascular access options. (Expert Opinion)
Summary of Guideline Statements
S30 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Guideline 17. AV Access Aneurysms
Statements: AV Access Aneurysms
Recognition and Diagnosis
17.1 KDOQI considers it reasonable to check AV access for aneurysm/pseudoaneurysms at each dialysis session by knowledgeable
care providers, including but not limited to dialysis technicians, nurses, nephrologists, and vascular access
coordinator. (Expert Opinion)
17.2 KDOQI considers it is reasonable to proactively educate patients on emergency procedures for aneurysm rupture and to
obtain proactive surgical assessment when clinical findings suggest an AV access aneurysm/pseudoaneurysm to be at risk
of complications. (Expert Opinion)
Note: An aneurysm/pseudoaneurysm that is considered at risk of complications is one with evidence of associated symptoms or skin
breakdown.
17.3 KDOQI considers it is reasonable to obtain emergent surgical assessment and treatment for AV access aneurysm/pseudoaneurysm
complications such as erosion or hemorrhage. (Expert Opinion)
17.4 KDOQI considers it reasonable to use duplex ultrasound to corroborate the physical examination suggesting an AV access
aneurysm/pseudoaneurysm and to obtain information on the size, presence of stenosis/thrombus, and impact on the AV
access (including flow rate [Qa] and status of the arterial inflow and the venous outflow). (Expert Opinion)
Management
17.5 KDOQI considers it reasonable that the presence of an aneurysm/pseudoaneurysm alone in the absence of symptoms (ie,
asymptomatic) is not an indication for definitive treatment. (Expert Opinion)
17.6 KDOQI considers it reasonable to avoid cannulating the access segment(s) that involve the aneurysm/pseudoaneurysm if
there are alternative sites. In the rare scenario where there are absolutely no suitable alternative cannulation sites, the
sides (base) of the aneurysm/pseudoaneurysm should be cannulated (ie, avoid the top). (Expert Opinion)
17.7 KDOQI considers it reasonable to obtain appropriate imaging of the arterial inflow and venous outflow to assess volume
flow or stenotic problems that may need correction prior to or during definitive treatment of symptomatic aneurysm/
pseudoaneurysm. (Expert Opinion)
17.8 KDOQI considers it reasonable that surgical management is the preferred treatment for patients with symptomatic, large,
or rapidly expanding AV access aneurysm/pseudoaneurysm (see “Treatment–Definitive” below). (Expert Opinion)
17.9 KDOQI considers it reasonable that a definitive surgical treatment is usually required for anastomotic aneurysms/pseudoaneurysms.
(Expert Opinion)
Treatment–Definitive
17.10 KDOQI considers it reasonable that open surgical treatment should be deemed the definitive treatment for AV access
aneurysms/pseudoaneurysms with the specific approach determined based on the local expertise. (Expert Opinion)
Note: This approach may include a plan for staged repair of multiple aneurysms to avoid bridging CVCs in the perioperative period.
17.11 KDOQI considers it reasonable to use covered intraluminal stents (stent grafts) as an alternative to open surgical repair of
AV access aneurysms/pseudoaneurysms, only in special circumstances such as specific patient contraindication to surgery
or lack of surgical option, due to the associated risk of infection in this scenario. (Expert Opinion)
17.12 KDOQI considers it reasonable that, should a stent graft be used to treat AV access aneurysms/pseudoaneurysm, cannulation
over the stent graft segment be avoided when possible. (Expert Opinion)
Note: The use of stent grafts to manage aneurysms/pseudoaneurysms is not an FDA-approved indication.
Prevention
17.13 KDOQI considers it reasonable that appropriate cannulation techniques should be implemented to reduce the occurrence
of AV access aneurysms/pseudoaneurysms (see Guideline Statement 11). (Expert Opinion)
Guideline 18. AV Access Steal
Statements: AV Access Steal
18.1 KDOQI considers it reasonable that strategies to both prevent and treat AV access steal should be developed and
implemented before AV access creation, to reduce the risk of AV access steal and related morbidity, respectively. (Expert
Opinion)
18.2 KDOQI considers it reasonable that post AV access creation, patients should be monitored closely for signs and symptoms
associated with AV access steal and managed appropriately with consideration of individual circumstances as follows
(Expert Opinion):
 Mild to moderate signs and symptoms require close monitoring for progression of ischemia and worsening of signs and
symptoms
 Moderate to severe signs and symptoms often require urgent treatment to correct the hemodynamic changes and
prevent any longer-term disability
18.3 KDOQI considers it reasonable that patients with signs and symptoms consistent with AV access steal should be referred
urgently to a surgeon/interventionist familiar with the diagnosis and options for the definitive treatment of AV access
complications, particularly AV access steal. (Expert Opinion)
18.4 KDOQI considers it reasonable that the optimal treatment of AV access steal should be determined based on the patient’s
clinical presentation, local expertise, and resources. (Expert Opinion)
Summary of Guideline Statements
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S31
Guideline 19. Other AV Access Complications
Statement: Management of AVG Seroma
19.1 KDOQI considers it reasonable to carefully monitor for complications of AVG seroma and manage based on the patient’s
individual circumstances and the clinician’s best judgment and discretion. (Expert Opinion)
Note: Operator’s/clinician’s discretion carefully considers both the patient’s individual circumstances and the operator’s/clinician’s own clinical
experience and expertise (ie, reasonable capabilities and limitations).
Statement: Management of High-Flow AV Access
19.2 KDOQI considers it reasonable to closely monitor and prophylactically manage AV access with high flows to avoid serious
or irreversible complications (eg, high output cardiac failure), based on the patient’s individual circumstances and the
clinician’s best judgment and discretion. (Expert Opinion)
Note: Operator’s/clinician’s discretion carefully considers both the patient’s individual circumstances and the operatot’s/clinician’s own clinical
experience and expertise (ie, reasonable capabilities and limitations).
Note: Close monitoring refers to physical examination and history on routine dialysis rounds and determination of Qa/CO every 6-12 months,
or more frequently as needed.
Guideline 20. Treatment and Prevention of CVC Complications
Statement: Monitoring/Surveillance of CVC Complications
20.1 KDOQI considers it reasonable to perform a basic medical history focused on signs and symptoms of CVC-related complications
(eg, dysfunction, infection) and physical examination or check of the dialysis catheter, exit site, tunnel, and
surrounding area at each catheter dressing change or dialysis session. (Expert Opinion)
Guideline 21. Catheter Dysfunction
Statement: Definition of CVC Dysfunction
21.1 KDOQI considers it reasonable to assess for CVC dysfunction during each HD session using the following updated
definition of CVC dysfunction: failure to maintain the prescribed extracorporeal blood flow required for adequate hemodialysis
without lengthening the prescribed HD treatment. (Expert Opinion)
Statements: Pharmacologic Prevention of CVC Dysfunction
CVC Connectors to Prevent CVC Dysfunction or Bacteremia
21.2 KDOQI considers it reasonable to have an individualized approach to use special CVC connectors based on the clinician’s
discretion and best clinical judgment. (Expert Opinion)
21.3 KDOQI considers it reasonable to use an antimicrobial barrier cap to help reduce CRBSI in high-risk patients or facilities;
the choice of connector should be based on clinician’s discretion and best clinical judgment. (Expert Opinion)
Intraluminal Agents to Prevent CVC Dysfunction
21.4 KDOQI considers it reasonable that the choice to use citrate or heparin as a CVC locking solution be based on the clinician’s
discretion and best clinical judgment, as there is inadequate evidence to demonstrate a difference in CVC survival
or complications between these locking solutions. (Expert Opinion)
21.5 KDOQI suggests the use of low-concentration citrate (<5%) CVC locking solution, if feasible, to help prevent CRBSI and
CVC dysfunction. (Conditional Recommendation, Low Quality of Evidence)
21.6 KDOQI suggests that TPA may be prophylactically used as a CVC locking solution once per week to help reduce CVC
dysfunction. (Conditional Recommendation, Low Quality of Evidence)
21.7 There is inadequate evidence for KDOQI to make a recommendation on the comparative use of the following CVC locking
agents for CVC dysfunction or infection prophylaxis: tinzaparin versus unfractionated heparin, taurolidine/citrate versus
heparin with or without gentamicin, neutral valve connector (Tego [ICU Medical]) versus citrate (46.7%) locking solution.
Systemic Agents to Prevent CVC Dysfunction
21.8 KDOQI recommends against the routine use of prophylactic systemic anticoagulants (eg, warfarin) for the sole purpose of
maintaining or improving CVC patency, as there is inadequate evidence of benefit for CVC patency but suggestion of
increased risk of harm. (Conditional/Strong Recommendation, Low Quality of Evidence)
21.9 KDOQI suggests that low-dose aspirin may be used to maintain tunneled CVC patency in patients with low bleeding risk.
(Conditional Recommendation, Low Quality of Evidence)
Note: CVC refers to tunneled hemodialysis CVCs unless otherwise specified.
Guideline 22. Treatment and Management of CVC Dysfunction
Statements: Medical Management of CVC Dysfunction
Conservative Maneuvers
22.1 KDOQI considers it reasonable for a conservative bedside approach to managing CVC dysfunction prior to other medical
or mechanical interventions. (Expert Opinion)
Summary of Guideline Statements
S32 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Pharmacologic Maneuvers
22.2 KDOQI recommends intraluminal administration of a thrombolytic agent in each CVC port to restore function
of dysfunctional CVCs due to thrombosis. (Conditional Recommendation, Moderate Quality of Evidence)
22.3 KDOQI recommends the use of alteplase or urokinase plus citrate 4% per limb for restoring intraluminal CVC blood flow in
an occluded CVC. (Conditional Recommendation, Moderate Quality of Evidence)
22.4 KDOQI suggests intraluminal administration of alteplase 2 mg in preference to alteplase 1 mg in each CVC port to restore
function of dysfunctional CVCs due to thrombosis. (Conditional Recommendation, Moderate Quality of Evidence)
22.5 KDOQI suggests administering alteplase by the dwell or push method to treat CVC dysfunction. (Conditional Recommendation,
Low Quality of Evidence)
Statements: Mechanical Management of CVC Dysfunction
22.6 KDOQI considers it reasonable that the decision to perform fibrin sheath disruption during CVC exchange for CVC
dysfunction be based on the operator’s discretion and best clinical judgment. (Expert Opinion)
22.7 There is inadequate evidence for KDOQI to make a recommendation on the efficacy of or method of fibrin sheath
disruption based on CVC patency outcomes.
22.8 KDOQI considers it reasonable that CVC removal followed by replacement at a different site should be the last resort after
conservative, medical, and other mechanical (eg, angioplasty, CVC exchange) strategies have all failed to treat CVC
dysfunction. (Expert Opinion)
Guideline 23. Catheter-Related Infection
Statements: Definitions of Catheter-Related Infections
23.1 KDOQI considers it reasonable to consistently use standardized definitions for CVC-related infections to allow for comparisons
across programs/jurisdictions. (Expert Opinion)
23.2 KDOQI considers it reasonable to use the KDOQI VA-2019 definitions of CVC-related infections (Tables 23.1 and 23.2),
which consider the unique circumstances of a hemodialysis patient. (Expert Opinion)
Note: In order to harmonize definitions, the KDOQI VA-2019 definitions encompass those of other organizations.
Guideline 24. Prevention of CVC-Related Infection
Statement: General Prevention of CVC Infection and Use of Infection Surveillance Programs and Infection Control Teams
24.1 KDOQ considers it reasonable for an infection control program to include an infection surveillance team to monitor, track
(in an electronic database), help prevent, and evaluate outcomes of vascular access infections and, in particular, CVCrelated
infections. (Expert Opinion)
Specific Prevention of CVC Infection
Routine monitoring per Guideline 20.1 is required for the prevention of CVC complications, including CVC-related infections.
Statement: Surveillance of CVC Colonization and Preemptive CRBSI Management
24.2 There is inadequate evidence for KDOQI to support routine CVC surveillance cultures for colonization and subsequent preemptive
antibiotic lock installation if culture is positive.
Statements: Methods to Prevent CRBSI
Extraluminal Strategies
See Guidelines 11, 21, and 24 on “CVC System Connect and Disconnect Procedure Considerations” and section on “Prevention of CVC
Dysfunction.”
Intraluminal Strategies
24.3 KDOQI suggests that the selective use of specific prophylactic antibiotic locks can be considered in patients in need of
long-term CVC who are at high risk of CRSBI (eg, multiple prior CRSBI), especially in facilities with high rates of CRBSI
(eg, >3.5/1,000 days). (Conditional Recommendation, Low-Moderate Level of Evidence)
Note: Under these circumstances and given the current data, KDOQI considers it reasonable for prophylactic use of specific antibiotics:
cefotaxime, gentamicin, or cotrimoxazole (TMP-SMX). KDOQI cannot support the routine prophylactic use of antibiotic locks with very low
supporting evidence (Table 24.1).
24.4 KDOQI suggests that the selective use of specific prophylactic antimicrobial locks can be considered in patients in need of
long-term CVC who are at high risk of CRSBI, especially in facilities with high rates of CRBSI (eg, >3.5/1,000 days).
(Conditional Recommendation, Low-Moderate Quality of Evidence)
Note: Under these circumstances and given the current data, KDOQI can support the prophylactic use of methylene blue. KDOQI cannot
support the routine prophylactic use of antimicrobial locks with very low supporting evidence (Table 24.1).
Summary of Guideline Statements
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S33
24.5 KDOQI suggests that the selective use of once weekly prophylactic CVC locking with thrombolytic agent (recombinant
TPA) can be considered in patients in need of long-term CVC who are at high risk of CRSBI, especially in facilities with high
rates of CRBSI (eg, >3.5/1,000 days). (Conditional Recommendation, Moderate Quality of Evidence)
Note: Under these circumstances and given the current data, KDOQI can support the prophylactic use of recombinant TPA.
Note: High-risk patients refers to those with prior multiple CRSBI, S aureus nasal carriers.
Guideline 25. Treatment of CVC-Related Infection
Statement: Management of the Patient With a CVC-Related Infection
25.1 KDOQI considers it reasonable and necessary to obtain appropriate cultures prior to initiating empiric antibiotics for the
treatment of suspected CVC-related infection, with a change in antibiotics according to culture sensitivities. (Expert
Opinion)
Statement: Management of the CVC in a Patient With a CVC-Related Infection
25.2 KDOQI considers it reasonable to have an individualized approach to the management of an infected catheter based on
the patient’s health, dialysis, and vascular access circumstances and should follow the detailed guidance. Options include
CVC exchange via guidewire, CVC removal and reinsertion, CVC salvage, and concurrent antibiotic lock (particularly if the
CVC is deemed to be the patient’s final access). (Expert Opinion)
Note: See Detailed Justification section for detailed guidance.
Guideline 26. Other Vascular Access-Related Complications
Statement: Treatment and Intervention of Asymptomatic Central Venous Stenosis Without Clinical Indicators
26.1 KDOQI considers it reasonable that if asymptomatic central venous stenosis (without clinical indicators) is identified and/
or associated with the prior or current presence of a CVC, it should not be treated. (Expert Opinion)
See Table 26.1 for clinical indicators of central venous stenosis.
Statement: Investigation and Treatment of Symptomatic Central Venous Stenosis With Clinical Indicators
26.2 Same as guidelines for “AV Access Flow Dysfunction–Confirmation And Treatment”
See Guideline 15. See Table 26.1 for clinical indicators of central venous stenosis.
Statement: Management of CVC Fibrin Sheath Associated With Clinical Problems
26.3 KDOQI considers it reasonable that when a CVC fibrin sheath is associated with adverse clinical manifestations (CVC
dysfunction and/or infection), a CVC exchange with or without balloon disruption of the fibrin sheath should be performed.
(Expert Opinion)
Summary of Guideline Statements
S34 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
KDOQI CLINICAL PRACTICE GUIDELINE FOR VASCULAR ACCESS
Guideline 1. Patient First: ESKD Life-Plan
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Note: Expert opinion statements that allow for the use of “the clinician’s
discretion and best clinical judgment” mean that there is currently
no rigorous evidence to recommend a therapy, device, or strategy over
another. The Work Group expects ERT-derived evidence-based statements
will ultimately replace expert opinion–based statements once such rigorous
evidence becomes available. The clinician’s discretion carefully considers
both the patient’s individual circumstances and the clinician’s own clinical
experience and expertise (ie, reasonable capabilities and limitations).
Statements: ESKD Life-Plan and Vascular Access
Choice
1.1 KDOQI considers it reasonable that each patient
with progressive CKD and/or with an eGFR 15-20
mL/min/1.73 m2
or already on kidney replacement
therapy should have an individualized ESKD
Life-Plan that is regularly reviewed, updated, and
documented on their medical record. (Expert Opinion)
1.2 KDOQI considers it reasonable to conduct an
annual review and update of each patient’s individualized
ESKD Life-Plan, together with their
health care team. (Expert Opinion)
1.3 KDOQI considers it reasonable that, in addition to
regular monitoring, a minimum quarterly overall
review and update of each patient’s vascular access
functionality, complication risks, and potential
future dialysis access options be done together with
their health care team. (Expert Opinion)
Rationale/Background
Who Needs Consideration for Hemodialysis
Vascular Access?
Patients with chronic kidney disease (CKD) who are either
preparing to initiate hemodialysis (predialysis), transitioning
from another kidney replacement modality
(peritoneal dialysis [PD] or failing/failed kidney transplant),
or are already on hemodialysis with a failing arteriovenous
(AV) access or hemodialysis catheter (CVC) will
need consideration for hemodialysis vascular access.
However, the actual need for hemodialysis vascular
access (vs a peritoneal dialysis access or preparation for
kidney transplantation) depends on the patient’s current
individualized End-Stage Kidney Disease (ESKD) Life-Plan
and the corresponding kidney replacement therapy (KRT)
modality choice and dialysis access (below). No decision about
a single vascular access creation or placement should be made in
isolation or independent of the patient’s overall ESKD Life-Plan.15
What Is the ESKD Life-Plan?
The ESKD Life-Plan is a strategy for living with ESKD,
ideally made together by the patient and a coordinated
CKD management team. For the purposes of dialysis access,
this team should include but is not limited to the
following professionals and supportive members:
nephrologist, surgeon, radiologist, nurse, patient family
member, or other supporter. The ESKD Life-Plan is a
strategy that should start in the predialysis period and
encompasses a continuum-of-care model for CKD to
ESKD. It aims to maximize ESKD modality choices and
utilization for a specific patient’s foreseeable lifespan and
specifically considers the patient’s current medical situation,
current and future life goals, preferences, social
support, functional status, and logistics and other practical
feasibilities.16
The ESKD Life-Plan maps out an individualized plan for
ESKD modalities for a patient; in doing so, the dialysis
access strategy is concurrently considered (Fig 1.1). It is an
iterative process because events occur in one’s life that may
change the patient’s medical, social, and other life circumstances
and goals, with corresponding alterations in
the patient’s ESKD Life-Plan.
Detailed Justification
Prior guidelines and initiatives have emphasized a “fistulafirst”
approach to vascular access choice due to the AV
fistula’s (AVF’s) associations with superior patency and
lower complications compared with other vascular access
types.13,17
However, more recent data have challenged
these associations because of the high complication rates of
AVF maturation failure requiring interventions and,
therefore, have prompted a re-evaluation of this Fistula
First approach.18-23
A patient-centered approach to hemodialysis
vascular access that considers multiple aspects
of a patient’s needs and dialysis access eligibility has been
emphasized.20,24-27
Vascular access remains a significant
challenge for patients with ESKD—we need to be creative
in not only thinking about how to prepare for, create, and
preserve durable long-term access but equally important, be
proactive in planning for the protection, creation, and preservation of the
NEXT vascular access, long before the current one fails. This chain of
careful, continual consideration of modalities and dialysis
access lifelines as it pertains to the individual patient’s
circumstances, needs, and preferences is the essence of the
ESKD Life-Plan.
Special Discussions
This concept of the ESKD Life-Plan relies on clear, timely,
and effective communication between the patient and their
Guideline 1. Patient First: ESKD Life-Plan
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S35
family/personal supporters and key team members. As
such, a kidney replacement modality and dialysis access
short- and long-term plan (ESKD Life-Plan) should be
updated on a regular basis. The frequency of re-evaluation
depends on the patient’s circumstances, but a minimum
annual basis is expected.
Implementation Considerations
Choice of Dialysis Access
Because the dialysis access strategy reflects the ESKD LifePlan,
whereby the appropriate dialysis access aligns with
the modality for kidney replacement therapy (dialysis or
transplant), it must be individualized to help each patient
achieve his or her life goals safely.
For example, a young active predialysis patient with
residual kidney function might best initiate peritoneal
dialysis with a PD catheter, in anticipation of a living
donor kidney transplant; because that transplant eventually
fails, this patient will receive a native AVF in view of
starting home hemodialysis, and so on. In contrast, an
older, more medically complex but functionally active
patient may have started hemodialysis urgently with a
central venous catheter, with plans to have a native AVF
created, with a back-up plan of a synthetic arteriovenous
graft (AVG) if the AVF fails to mature in a timely fashion,
to avoid prolonged CVC dependence. Finally, a palliative
patient may best be served with an early cannulation graft
or CVC for shorter-term hemodialysis.
Guidance is provided by Figs 1.1 through 1.6.
Another supportive tool to help guide the choice of
vascular access based on patient and vessel characteristics/
circumstances is available at www.myvascularaccess.com.
Monitoring and Evaluation
Attainment of the “right access, in the right patient, at the
right time, for the right reasons” is a more patientcentered
approach to care, where population measures,
such as percentage with AVF created or used, or the percentage
with hemodialysis CVC may be unhelpful and counterproductive
for patient-centered goals.
How does one achieve “the right access, in the right
patient, at the right time, for the right reasons”? The Work
Group suggests considering (1) the patient first, followed
by (2) dialysis access needs—this is done by creating their
individual P-L-A-N. See Fig 1.1.
Concurrently, there must always be a Vessel Preservation
Plan, to ensure viability for future access. Therefore,
for each vascular access, the Access Needs must
include 4 plans: the Vessel Preservation, Insertion/Creation,
Contingency, and Succession plans. This comprehensive
plan for a patient’s access needs can be
remembered as ViP ACCeS plans: Vessel important Preservation,
Access Creation, Contingency, and ESKD access
Succession plans.
A number of measures can be used to monitor a dialysis
facility, including the percentage of patients with a P-L-AN
on record.
Specific measures for each vascular access type can be
found in Goals and Targets section of this document.
Figure 1.1. ESKD and Dialysis Access Life Plan: What’s the P-L-A-N? Abbreviations: HD, hemodialysis; PD, peritoneal dialysis; KRT, kidney
replacement therapy.
Guideline 1. Patient First: ESKD Life-Plan
S36 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
The Pre-KRT Pa ent Being Considered for Hemodialysis
What is the likelihood of long-term survival? (eg, > 1 year)
Consider Age, Comorbidi es, Func onal Status, Social Supports, Pa ent’s Goals and Preferences
Poor:
Watch, Wait and Re-assess Approach
Good:
Assess for Appropriateness of AV-access+
Consider AVG
(pa ent preference)
Has situa on changed or improved?
No
HD needed (eg, pallia ve HD^)
Consider CVC
(pa ent preference)
or
Yes
No Yes
Good:
Assess for Appropriateness of AV Access+
*Loca on needs to consider subsequent
accesses placements
+May use app for guidance
^See Guidelines for defini on
High likelihood of AVF success and limited CVC dependency (consider age, comorbidi es,
vessel suitability*)?; consider vascular sites available, prior access failure, future access
sites and possibili es
Is this pa ent a good AVF candidate?
No Yes
Consider AVG*
Is secondary AVF possible when AVG becomes
problema c?
No
Con nue with AVG
Consider
AVF*
Yes
Figure 1.2. The pre-KRT patient being considered for hemodialysis. Abbreviations: AV, arteriovenous; AVF, arteriovenous fistula; CVC, central
venous catheter; HD, hemodialysis; KRT, kidney renal replacement therapy; PD, peritoneal dialysis.
The Pa ent Is Already on Hemodialysis With a CVC
Is an AV access appropriate and possible?
Central stenosis, poten al access loca ons, medically & surgically feasible?
Yes+No
Con nue with CVC
Yes
Is this pa ent a good AVF candidate?
*Loca on needs to consider subsequent accesses placements
+May use app for guidance
Consider AVF
Is secondary AVF possible when AVG becomes
problema c?
Con nue with AVG
No
Consider AVG
No
Consider likelihood of AVF success/ failure (age, comorbidi es, vessel suitability*), vascular
sites available, prior access failure, future access sites and possibili es
Yes
Figure 1.3. The patient is already on hemodialysis with a CVC. Abbreviations: AV, arteriovenous; CVC, central venous catheter.
Guideline 1. Patient First: ESKD Life-Plan
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S37
The Patient Is Already on Hemodialysis With a Failing AV Access
Is AV access appropriate and possible?
Is the patient using a CVC?
Consider likelihood of AVF success/ failure
(age, comorbidities, vessel suitability*),
vascular sites available, prior access failure,
future access sites and possibilities
Consider AVG
Consider AVF
Is this patient a good AVF
candidate?
*Location needs to consider subsequent
access placements
+May use app for guidance
Is secondary AVF possible when AVG
becomes problematic?
Continue with
AVG
CVC
Consider central stenosis or other anatomic barriers, poten al access loca ons,
medically & surgically feasible?
Is there high risk of AVF maturation
failure and/or prolonged CVC
dependency?
Yes
Yes+
No
No
No
No
No
Yes
Yes
Yes
Figure 1.4. The patient is already on hemodialysis with a failing AV access. Abbreviations: AV, arteriovenous; AVF, arteriovenous fistula; CVC, central
venous catheter.
What is the likelihood of long-term survival? (eg, >1 year)
Consider Age, Comorbidi es, Func onal Status, Social Supports, Pa ent’s Goals and Preferences
Poor:
Watch, Wait, and Re-assess Approach
Has situa on changed or improved?
No
Nondialy c Care or Pallia ve HD
Consider CVC or AVG
(pa ent preference)
Yes
No Yes
Good:
Assess for appropriateness of AV access+
*Loca on needs to consider subsequent
access placements
+ May use app for guidance
High likelihood of AVF success and limited CVC dependency (consider age, comorbidi es,
vessel suitability*)?; consider vascular sites available, prior access failure, future access
sites and possibili es
Is this pa ent a good AVF candidate?
No Yes
Consider AVG*
Is secondary AVF possible when AVG becomes
problema c?
No
Con nue with AVG
Consider
AVF*
Yes
The Peritoneal Dialysis Patient is Being Considered for HD (See Table 6.1)
Figure 1.5. The peritoneal dialysis patient is being considered for HD. Abbreviations: AV, Arteriovenous; AVF, Arteriovenous fistula; CVC, Central
venous catheter; HD, hemodialysis.
Guideline 1. Patient First: ESKD Life-Plan
S38 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Who Should Update the ESKD Life-Plan and
Associated Dialysis Accesses?
Ideally, the ESKD Life-Plan should be discussed with the
patient within a multidisciplinary team framework
(nephrologist, surgeon, interventionalist). If not feasible,
the nephrologist should discuss modality options with the
patient, with referral to surgeon/interventionalist for input
on the appropriate dialysis access that corresponds to the
chosen KRT modality.
Who Should Document the ESKD Life-Plan and
Associated Access Changes?
The documentation of the ESKD Life-Plan should be the
responsibility of the nephrologist and accompany the patient’s
medical record/chart.
A sample template can be found in Supplement 2:
ESKD Life Plan—Patient-Physician Shared
Documentation.
Future Research
The use of the ESKD Life-Plan strategy must be evaluated.
Key outcomes should include
 Patient satisfaction with the dialysis access, using a
validated instrument
 Rate of unnecessary dialysis access creations/placements
 Rate of vascular access procedures
 Rate of vascular access infections
 Rate of vascular access–related hospitalizations
 Patient burden, which may include all of the above
components
Guideline 2. Vascular Access Types
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: AV Access: Indications for Use
2.1 KDOQI considers it reasonable to have an AV access
(AVF or AVG) in a patient requiring HD, when
consistent with their ESKD Life-Plan and overall
goals of care. (Expert Opinion)
Note: See specific sections on incident and prevalent patients and the
choice of AV access type and their appropriate locations
Statements: Central Venous Catheters (CVC):
Indications for Use
2.2 KDOQI considers it reasonable in valid clinical
circumstances to use tunneled CVCs for short-term
or long-term durations for incident patients, as
follows (Expert Opinion):
Short-term duration:
 AVF or AVG created but not ready for use and
dialysis is required
 Acute transplant rejection or other complications
requiring dialysis
What is the likelihood of long-term survival? (eg, >1 year)
Consider Age, Comorbidi es, Func onal Status, Social Supports, Pa ent’s Goals and Preferences
Poor:
Watch, Wait, and Re-assess Approach
Has situa on changed or improved?
No
Nondialy c Care or Pallia ve HD
Consider CVC or AVG
(pa ent preference)
Yes
No Yes
Good:
Assess for Appropriateness of AV access+
High likelihood of AVF success and limited CVC dependency (consider age, comorbidi es,
vessel suitability*)?; consider vascular sites available, prior access failure, future access
sites and possibili es
Is this pa ent a good AVF candidate?
No Yes
Consider AVG*
Is secondary AVF possible when AVG becomes
problema c?
No
Con nue with AVG
Consider
AVF*
Yes
The Transplant Patient Being Considered for HD#
#When eGFR <30 mL/min/1.73 m2, transplant
patient should be referred to nephrologist for
pre-KRT planning
*Location needs to consider subsequent and
future vascular access placements
+May use app for guidance
Figure 1.6. The transplant patient is being considered for HD. Abbreviations: AV, arteriovenous; AVF, arteriovenous fistula; CVC, central venous
catheter; eGFR, estimated glomerular filtration rate; HD, hemodialysis; RRT, renal replacement therapy.
Guideline 2. Vascular Access Types
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S39
 PD patient with complications that require
time-limited peritoneal rest or resolution of
complication (eg, pleural leak)
 Patient has a living donor transplant confirmed
with an operation date in the near future (eg, <90
days) but requires dialysis
 AVF or AVG complication such as major infiltration
injury or cellulitis that results in temporary
nonuse until problem is resolved
Note: In special, limited circumstances where temporary CVC is
required to manage a vascular access complication (eg, <2 weeks),
it may be acceptable to use a nontunneled CVC.
Long-term or indefinite duration:
 Multiple prior failed AV accesses with no available
options (see anatomic restrictions below)
 Valid patient preference whereby use of an AV
access would severely limit QOL or achievement
of life goals and after the patient has been
properly informed of patient-specific risks and
benefits of other potential and reasonable access
options for that patient (if available)
 Limited life expectancy
 Absence of AV access creation options due to a
combination of inflow artery and outflow vein
problems (eg, severe arterial occlusive disease,
noncorrectable central venous outflow occlusion)
or in infants/children with prohibitively
diminutive vessels
 Special medical circumstances
Statements: Vascular Access for Incident Patients
The statements below are in the context of the ESKD Life-Plan and
associated Access Algorithms and their considerations, such as
patient comorbidities, circumstances, etc (Figs 1.1-1.6).
2.3 KDOQI suggests an AV access (AVF or AVG) in
preference to a CVC in most incident and prevalent
HD patients due to the lower infection risk associated
with AV access use. (Conditional Recommendation,
Low Quality of Evidence)
2.4 KDOQI considers it reasonable that the choice of
AV access (AVF or AVG) be based on the operator’s/clinician’s
best clinical judgment that considers
the vessel characteristics, patient
comorbidities, health circumstances, and patient
preference. (Expert Opinion)
2.5 KDOQI suggests that if sufficient time and patient
circumstances are favorable for a mature, usable
AVF, such a functioning AVF is preferred to an
AVG in incident HD patients due to fewer longterm
vascular access events (eg, thrombosis, loss
of primary patency, interventions) associated
with unassisted AVF use. (Conditional Recommendation,
Low Quality of Evidence)
Note: Patient circumstances refer to vessel characteristics, patient
comorbidities, health circumstances, and patient preference.
Note: Unassisted AVF use refers to an AVF that matures and is used
without the need for endovascular or surgical interventions, such as
angioplasty. A preplanned vessel superficialization is acceptable and
not considered an additional intervention.
2.6 KDOQI suggests that most incident HD patients
starting dialysis with a CVC shouldconvert toeither
an AVF or AVG, if possible, to reduce their risk of
infection/bacteremia, infection-related hospitalizations,
and adverse consequences. (Conditional
Recommendation, Very Low-Moderate Quality of Evidence)
2.7 There is inadequate evidence for KDOQI to make
recommendations on choice of incident vascular
access type based on associations with all-cause
hospitalizations or mortality.
2.8 There is inadequate evidence for KDOQI to make
a recommendation on choice of AVF vs AVG for
incident vascular access based on associations
with infections, all-cause hospitalizations, or
patient mortality.
2.9 There is inadequate evidence for KDOQI to make
a recommendation for incident HD patients using
a CVC on converting to an AV access (AVF or
AVG) within the first year of dialysis initiation,
solely to reduce their risk of mortality.
2.10 KDOQI considers it reasonable to use tunneled
CVC in preference to nontunneled CVC due to the
lower infection risk with tunneled CVC. (Expert
Opinion)
2.11 KDOQI considers it reasonable to use nontunneled
internal jugular CVC only for temporary
purposes for a limited time period (<2
weeks or per individual facility policy) to limit
infection risk. (Expert Opinion)
Statements: Vascular Access in Prevalent HD
Patients
2.12 There is inadequate evidence for KDOQI to make
a recommendation on the type of vascular access
preferred in prevalent HD patients based on
vascular access outcomes, patient hospitalizations,
or mortality.
2.13 KDOQI considers it reasonable that prevalent HD
patients use an AV access (AVF or AVG) in preference
to a CVC, if possible, due to the association with
lower vascular access–related events (eg, infection,
thrombotic, and nonthrombotic complications).
(Expert Opinion)
2.14 KDOQI considers it reasonable that if clinical
circumstances are favorable for a mature, usable
Guideline 2. Vascular Access Types
S40 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
AVF, such a functioning AVF is preferred to AVG
in prevalent HD patients. (Expert Opinion)
Note: Clinical circumstances refer to patient’s vessel characteristics,
comorbidities, health circumstances, potential exposure time to
CVC use, and patient preference.
2.15 KDOQI considers it reasonable in valid clinical
circumstances to use tunneled CVCs for short-term
or long-term durations in prevalent dialysis patients,
as follows (Expert Opinion):
Short-term duration:
 AVF or AVG created but not ready for use and
dialysis is required
 Acute transplant rejection or other complications
requiring dialysis
 PD patient with complications that require
time-limited peritoneal rest or resolution of
complication (eg, pleural leak)
 Patient has a living donor transplant confirmed
with an operation date in the near future (eg, <90
days) but requires dialysis
 AVF or AVG complication such as major
infiltration injury or cellulitis that results in
temporary nonuse until problem is resolved
Note: In special, limited circumstances where temporary CVC is
required to manage a vascular access complication
(eg, <2 weeks), it may be acceptable to use a nontunneled CVC.
Long-term or indefinite duration:
 Multiple prior failed AV accesses with no
available options (see anatomic restrictions
below)
 Valid patient preference whereby use of an AV
access would severely limit QOL or achievement
of life goals and after the patient has been
properly informed of patient-specific risks and
benefits of other potential and reasonable access
options for that patient (if available)
 Limited life expectancy
 Absence of AV access creation options due to a
combination of inflow artery and outflow vein
problems (eg, severe arterial occlusive disease,
noncorrectable central venous outflow occlusion)
or in infants/children with prohibitively
diminutive vessels
 Special medical circumstances
Rationale/Background
Incident Patients
Ideally, a CKD patient will have been properly educated
about KRT modalities and will have made an informed
choice in a timely manner to allow for planned HD start
with the appropriate dialysis access—to achieve the right access,
in the right patient, at the right time, for the right reasons. However,
prior to executing the plan to create or insert the chosen
vascular access, the “contingency access plan and
succession strategy” for the chosen dialysis access must be
considered that incorporates the patient’s various ESKD
Life-Plan options (Guideline 1). The contingency plan is a
plan to remediate a problematic or failing dialysis access,
and the succession strategy is the preparation and planning
of the next dialysis access so that it can be used when the
current one fails, to ensure continual functioning dialysis
access throughout the patient’s life.
Incident dialysis patients are often overwhelmed by
dialysis initiation and the lifestyle changes required. If the
dialysis initiation is urgent or emergent, the patient may not
have had a choice of vascular access and initiated with a CVC.
However, once circumstances are stabilized, long-term
vascular access must be carefully considered and pursued.
The long-term choice of vascular access should consider the
patient’s current and future ESKD Life-Plan (Guideline 1).
Given these considerations, we recognize that prior
guidelines generally supported the notion that the AVF was
associated with improved outcomes (superior patency,
lower complications, lowest cost)13
compared with an AVG
or CVC. The previous guideline statements were based on
older evidence and analytic concepts. We now recognize the
significant biases associated with the prior data, given newer
data and analytic considerations. As an example, prior
patency comparisons of AVFs versus AVGs evaluated only
AVFs that were successfully used and excluded AVFs that had
primary failure or were abandoned without use.28,29,30
The
impact of concluding AVF “superiority” led to the creation
of many AVFs that were not usable for dialysis31-33
. Any
vascular access not usable for dialysis should be considered a
complication attributable to that vascular access. Thus, this
bias in analysis affects the findings of superiority of both
AVF patency and complication rate. Additionally, multiple
biases exist in comparisons of CVC with either an AVF or
AVG.34-36
The most apparent is the selection bias found in
patients who have significant comorbidity and poor vessels
who may not be eligible for an AV access or for whom their
social, functional, or other circumstances are so poor that an
emergent dialysis start with CVC is necessary—these confounding
factors may be the very factors responsible for
poor outcomes and not necessarily the use of the CVC per se.
The repercussions of such biases are many, including the
potentially misleading association of mortality and VA type,
with CVC associated with the worse mortality. Although,
indeed, each VA type has unique advantages and disadvantages—and
the disadvantages of CVC may contribute
to poor patient outcomes—the true magnitude of this effect
is not certain in view of the selection bias and confounding
effects inherent in the observational data that informed the
previous guidelines.
The past decade has brought insight regarding the effect of
changing patient characteristics; health care environments;
processes, measurements and definitions surrounding dialysis
delivery; and data analytic techniques—all of which influence
hemodialysis vascular access choice and management. This
Guideline attempts to consider these insights and bring a fresh
slate to revisit vascular access choice and management.
Guideline 2. Vascular Access Types
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S41
Guideline 3 will discuss the location or site of vascular
access creation/insertion after the type of vascular access is
chosen.
Studies Evaluated for Incident and Prevalent
Patients
These guidelines reviewed 33 reports of 32 observational
studies evaluating different vascular access types in incident
and prevalent patients using prospectively collected data
from clinical or administrative databases or registries;
however, no RCTs met predefined search criteria relevant to
this Guideline (Supplement 3, Table S1).18,21,30,37-66
The
references to these studies are summarized in Table 2.1.
In addition, 4 studies were superseded by other studies
using a more recent series of the same cohort and reporting
the same outcomes38,41,44,62
; 7 studies contributed less than
3% to the total population for a specific
comparison37,40,45,46,49,54,63
; and 6 studies had high risk of
bias.21,30,43,47,58,64
Data from those studies were not
extracted or used in analysis. Thus, data from 16 studies
were extracted and analyzed (Supplement 3, Tables S2 and
S4). Although the ERT attempted to pool data for analysis to
provide information to make recommendations, it may not
have been possible due to differences in outcome definitions.
For example, in comparisons between AV access
types, there was variation in the start time for time-to-event
analysis (eg, patency calculation) such that some analyses
started (t = 0) when the vascular access was successfully
cannulated and used but others started (t = 0) at the time of
creation. As discussed, such methodologic differences are
important to consider when interpreting the data.
Detailed Justification
Vascular Access in Incident Patients
Four studies48,55,56,65
(total n = 570,003 incident HD patients)
reported on the associations of vascular access type
and bloodstream infection or mortality. Bloodstream infections
were significantly lower among patients starting HD
with an AVF (6.4%) versus a CVC (15%) (hazard ratio [HR],
0.28; 95% confidence interval [CI], not reported; P < 0.001;
unadjusted relative risk [RR], 0.43; 95% CI, 0.38-0.48) or
an AVG (7.5%) versus a CVC (15%) (HR, not reported; P <
0.001; unadjusted RR, 0.50; 95% CI, 0.41-0.60).65
Although AVF or AVG was associated with lower
mortality compared with CVC (Fig 2.1), the evidence
quality was low with moderate risk of bias; thus, choice of
vascular access type should not be based on mortality risk
associations alone.
This caution holds true even when considering age as an
effect modifier. Three studies examined 127,389 incident HD
patients, focusing on mortality outcomes among older pa-
tients.42,61,66
Mortality was significantly lower with an AVF
or AVG versus a CVC among patients <80 years old; findings
were inconsistent in analysis of patients >80 years old.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S1-S7.
Vascular Access in Prevalent Patients
Three studies enrolled a total of 82,657 prevalent HD patients
with at least 12 months of follow-up from the United
States, Spain, and Scotland.39,50,60
The quality of evidence
was insufficient to determine associations between vascular
access type and hospitalizations or mortality. Only 1 study
reported primary patency,60
which was described as “first
vascular access event”: 86% for AVF, 51% for AVG, and
56% for CVC at 1 year (P < 0.001).60
However, the
reporting of vascular access events was rated as having
moderate risk of bias. Furthermore, there were no details
on whether vascular accesses were first or subsequent accesses
and practice patterns have since changed (prevalent
cohort began treatment 1999-2001 in the study by Portoles
et al60
). Thus, the Work Group decided against making
KDOQI recommendations based on these data. Recent
studies have highlighted concerns of selection bias and its
potential impact on outcomes.19,34,35,67-69
In specific comparisons of AVF versus AVG, vascular
access events (thrombosis, AVG repair, or hospitalization
for a vascular access problem [unadjusted RR, 0.27; 95%
CI, 0.20-0.36] in Portoles et al60
or for any cause [HR,
0.81; 95% CI, 0.79-0.83] in Lacson et al,50
were lower
with an AVF than an AVG. Mortality was also lower with
an AVF than an AVG (HR, 0.89; 85% CI, 0.84-0.93) in
Lacson et al.50
Again, due to the poor quality of the evidence,
the Work Group decided against making KDOQI
recommendations based on these data.
Tables of studies, evidence quality, and bias are provided
in Supplement 3, Tables S1-S4 and S10.
The quality concerns noted by the ERT are further supported
by recent studies highlighting the considerable biases
in prior studies comparing vascular access types, vascular
access complications, and patient outcomes.34-36,67-69
The
uncertainty generated by the observational data informed the
Work Group in reframing the previous 2006 KDOQI
guideline and is reflected by the following:
1) The differences in AVF and AVG patency are uncertain
and depend on the starting time of analysis, as originally
noted in early observations of AVF patency.70
Table 2.1. Access Type Comparison Studies Reviewed
Comparison
Number of
Studies References
AVF or AVG vs CVC 19 37-39,41-
44,46,49,50,55,56,60-
63,65,66
AVF vs AVG 8 18,21,30,40,41,45,53,54,59
AVG (thigh) to CVC 1 58
AVF (upper extremity) vs AVG
(lower extremity)
1 47
No change in access type vs
change in access type
4 51,52,57,64
Abbreviations: AVF, arteriovenous fistula; AVG, arteriovenous graft; CVC,
central venous catheter.
Guideline 2. Vascular Access Types
S42 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Subsequent studies have demonstrated equivalency of
AVF and AVG patency.30,71-73
2) There are few RCTs informing the comparisons of AVF
versus AVG; those that have been done in fact
demonstrate that there may be benefit of AVG,
including in patients with poor vessels and greater
comorbidity than in those with AVF.74,75
3) The statement that AVFs may have fewer complications
compared with AVGs may not be generalizable to all
AVFs and AVGs and may further depend on what
constitutes a complication. The increase in AVF creation
has identified a significant and variably high rate of AVF
failure to mature or nonusability for dialysis (20%-
60%).14,17,24,30,33,76,77
This nonusability for dialysis
should be considered a complication, particularly
because it requires interventions (eg, angioplasty,
balloon-assisted maturation [BAM], ligations, etc) to
facilitate its use and/or CVC insertion if dialysis is
needed. Any need for an unintended intervention,
including CVC insertion, should be considered a
complication. This is well known for AVG thrombosis
and the required corrective interventions (angioplasty,
thrombectomy, or surgical revision). In general, complications
occur early in AVFs and later in AVGs—the
total rate of complications for AVFs or AVGs has not
been compared. This is particularly important when
considering the required lifespan of an AV access to
serve the patient, according to their ESKD Life-Plan. See
case examples.
Special Discussions
When analyzing vascular access outcomes, it is important to
clarify the “incident/prevalent” designation. In some
studies, the “incident/prevalent” status refers to the patient’s
status—not the vascular access status. The vascular access
used in an incident dialysis patient may not necessarily mean
it was the patient’s first access. For example, an incident
patient starting dialysis with a CVC may have had a prior
failed AVF. Similarly, an incident HD patient using an AVF
may have had a prior failed AVF; the behavior of a first versus
a subsequent access and the impact on the patient may differ.
Clearly, the implications of both the patient status (as
incident or prevalent on dialysis) and of the vascular
access (as first or subsequent) are related; however, their
relative contributions to the outcome of interest are unclear
and likely to depend on clinical circumstances. For
example, at time of analysis, a prevalent hemodialysis
patient who has a successful functioning AVF as the
“first” vascular access is different than a prevalent dialysis
patient who has had multiple failed AVFs and is now
analyzed with a CVC as the “prevalent” (or “subsequent”)
vascular access—both patient and vascular access
outcomes would likely differ, even though they are both
considered “prevalent.” These analyses do not provide
information in that regard, and the associative findings
should be considered in that light.
To further complicate matters, the definitions of
important vascular access outcomes (such as “patency”)
have been highly inconsistent, making it challenging, if not
impossible, to make valid comparisons between vascular
access types and between studies.1,78
For example, as discussed
under vascular access for incident patients, prior
patency comparisons of AVFs versus AVGs evaluated only
AVFs that were successfully used and excluded AVFs that
had primary failure or were abandoned without use.29,33
The impact of concluding AVF superiority on this premise
led to the creation of many AVFs that were not usable for
dialysis.30,33,76
Any vascular access not usable for dialysis
should be considered a complication attributable to that
vascular access. Thus, this bias in analysis affects the findings
of both AVF patency superiority and complication rate.
The current KDOQI Guidelines on the choice of vascular
access in prevalent patients reflect the prior inconsistencies
in definitions and biases in analyses and interpretation in
the existing literature. Future research is recommended to
provide the necessary data required to make recommendations
on type of vascular access for incident and prevalent
patients in need of first or subsequent accesses. Please
see the Research Recommendations section.
Mortality AVF/AVG versus CVC among Incident patients
0.5 0.75 Fistula or Graft
Graph Generated by Distiller SR
Catheter 1.25
1.0
Study Name
Malas 2015
Moist 2015
Kanza 2016
Not pooled
HR LCL UCL
0.69 0.68 0.70
0.63 0.57 0.69
0.56 0.46 0.63
0 0 0
Figure 2.1. Hazard ratio for mortality with AVF or AVG versus catheter among incident HD patients. When HRs were reported as catheter versus
AVF/AVG, ratios were inverted for consistency within display. Data were not pooled but are presented here for display only. Plot was made using
DistillerSR Forest Plot Generator from Evidence Partners. Abbreviations: AVF, arteriovenous fistula; AVG, arteriovenous graft; HR, hazard ratio;
LCL, lower confidence limit; UCL, upper confidence limit.
Guideline 2. Vascular Access Types
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S43
Implementation Considerations
See Fig 2.2.
It is important to emphasize that the primary goal of vascular access
creation and planning is to create a functional vascular access that can
provide reliable prescribed dialysis, with minimal interventions and
complications.15,79
Please see the section on “KDOQI Vascular Access
Guidelines Goals and Targets.” The outcomes of AV
accesses that have required interventions before use
may have a different natural history than those not
needing interventions (unassisted matured AV
accesses). Further comparative study is required; until
such time, caution should be made in generalizing the
outcomes of AVF and AVG noted in prior literature that
have not taken this into consideration.1
Special Populations: Pediatrics
The choice of vascular access for pediatric HD patients
must take a number of factors into account. For incident
patients with an unplanned dialysis initiation and who
desire HD for KRT, a CVC will be necessary irrespective
of age, body habitus, venous anatomy, or comorbidities.
Figure 2.2. ESKD Life-Plan case examples. Abbreviation: ESKD, end-stage kidney disease.
Guideline 2. Vascular Access Types
S44 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Placement of CVC may be required in patients with small
or diminutive vessels that are not suitable for an AVF or
AVG, but this should be considered a “bridge” or
midterm solution until the vessel, sizes are adequate.
There is no specific size cutoff in terms of weight or
vessel diameter in this setting, and, thus, the timing for
access creation (AVF or AVG) should be based on patient
circumstances and local expertise. The use of CVC is
associated with higher risk of bloodstream infections,
greater hospitalization rates and antibiotic use with potential
nephrotoxic effects on residual kidney function,
and damage to central vessels making future AV access
creation difficult. As such, pediatric dialysis centers must
be committed to insightful best care for their patients—
this current year and next as an integral part of their
ESKD Life-Plan, which will include HD, transplant, and
PD. The choice of AVF is preferred over AVG but may be
dictated by available vascular anatomy, other clinical
factors, and local surgical expertise for AV access creation
and interventional radiology expertise for maintaining AV
access function. The benefit margin of AVF over CVC in
pediatrics has been well documented.79-80
However, evidence
demonstrating the superiority of AVF over AVG, is
less available in the pediatric hemodialysis patient.81
The best first strategy is CVC avoidance followed by
CVC minimization. Furthermore, for patients/families
who are eligible and desire PD (even if needed acutely),
urgent placement of a PD catheter is recommended to
avoid the risks and long-term morbidities associated with
CVC placement, even if used only for a few weeks to
months.83
Future Research
 Studies evaluating first versus subsequent accesses
 RCT of various types—this is critical but challenging
and may be impossible
 Consider complication rate as an outcome (define what
is viewed as a complication— eg, for AVFs that fail to
mature, use of a CVC may be deemed a complication,
etc)
 Validation of standardized definitions for patency and
complications
Guideline 3. Vascular Access Locations
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: AV Access Locations
The statements below are in the context of the ESKD Life-Plan and
associated Access Algorithms and their considerations (eg, feasible anatomy,
etc).
Note: See Guideline Statements 2.2 and 3.2 for CVC use and
location; this section refers to AVF or AVG.
3.1 KDOQI considers it reasonable to choose the site
(location) of the AV access (AVF or AVG) after
careful consideration of the patient’s ESKD LifePlan
(Figs 1.1-1.6), potentially following the
below paths (Expert Opinion). See Guideline Statement
3.2 for CVC locations:
A) A patient’s ESKD Life-Plan includes an anticipated
long duration (eg, >1 year on HD):
 Forearm AVF (snuffbox or distal radiocephalic
or transposed radiobasilic)
 Forearm loop AVG or proximal forearm AVF
(eg, proximal radiocephalic, proximal
vessel, and perforator combinations) or
brachiocephalic, per operator discretion
 Brachiobasilic AVF or upper arm AVG, per
operator discretion
B) A patient’s ESKD Life-Plan includes an anticipated
limited duration (eg, <1 year) on HD:
 Forearm loop AVG or brachiocephalic AVF
(with high likelihood of unassisted
maturation)
 Upper arm AVG
C) A patient urgently starts HD without prior
sufficient time to plan for and/or create an AV
access and has an anticipated limited duration
(eg, <1 year) on HD:
 Early or standard cannulation loop AVG
(forearm or upper arm location), or CVC, per
operator discretion and patient’s clinical needs
Note: The choice of upper extremity location of an AVG should be
based on the operator’s discretion and best clinical judgment
considering the patient’s ESKD Life-Plan, due to inadequate
evidence to demonstrate a difference between forearm versus
upper arm AVG patency or complication outcomes (including
infections, hospitalizations, and mortality).
D) A patient urgently starts HD without prior
sufficient time to plan for and/or create an AV
access and has an anticipated long duration (eg,
>1 year) on HD:
 PD catheter, and follow above algorithm (A)
if PD not a long-term option or
 Forearm early cannulation loop graft; when
AVG fails, follow above algorithm (A) or
 CVC if high likelihood of rapid AVF maturation
and usability success, then follow
above algorithm (A)
Guideline 3. Vascular Access Locations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S45
E) All AV access options in the upper extremity
have been exhausted and patient’s ESKD LifePlan
includes a long duration (eg, >1 year) on
HD, the following may be considered based on
individual patient circumstances and operator’s
best clinical judgment and expertise:
 Lower extremity AVF or AVG or HeRO Graft
While a suggested stepwise approach to AV access site selection is
provided (Figs 1.1-1.6), modification of the approach is
encouraged as necessary to consider the individual’s ESKD
Life-Plan and circumstances, and follow the below key
principles, given available suitable vessels:
n Distal first to proximal next approach
n Always preserve the integrity of vessels for future vascular
access options
n Nondominant extremity in preference to dominant, only
if choices are equivalent
Statements: CVC Locations
3.2 KDOQI considers it reasonable to choose the site
(location) of the CVC after careful consideration of
the patient’s ESKD Life-Plan as follows (Expert
Opinion):
 Upper extremity before lower extremity, only if
choices are equivalent
 There are valid reasons for CVC use (Guideline
Statement 2.2) and its duration of use is expected
to be limited (eg, <3 months):
 AV access is likely to be ready for use in near
future—consider preferential use of tunneled
cuffed CVC in opposite extremity to anticipated
AV access
 Transplant is anticipated in near future (ie, preserve
iliac vessels) —consider preferential use of
tunneled cuffed right IJ catheter
Note: See below guidance for more details on CVC location.
 Some experts support that in urgent dialysis start
situations, under limited use circumstances (eg, <1
month) and transplant is not an option, use of a
tunneled, cuffed femoral CVC is acceptable (unless
contraindicated) until the AV access or PD catheter
can be quickly created and used. Use of the femoral
vein preserves the upper extremity vessels for
future AV access creation.
Note: Contraindications to femoral vein CVC include femoral or
iliac vessel pathology or prior surgery/reconstruction; hygienic
reasons (eg, chronic unresolved diarrhea), morbid obesity
(BMI>35 kg/m2
), or other difficult vein access.
 When there are valid reasons for CVC use
(Guideline Statement 2.2) and duration of use is
expected to be prolonged (eg, >3 months)
without anticipated use of AV access, CVC may be
placed in the following locations in order of
preference:
 Internal jugular
 External jugular
 Femoral
 Subclavian
 Lumbar
Note: In the absence of contraindications, prior pathology (eg,
central stenosis) or intervention (eg, pacemaker) CVC insertion
on the right side is preferable to the left side due to more
direct anatomy. 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.
Rationale/Background
Patients with CKD/ESKD are surviving longer with variable
ESKD Life-Plans,83
made possible by optimizing the use of
all modality options. High rates of AVF maturation failure,
recurrent thrombosis of AVGs, and CVC-related infections
and central stenosis have made the planning of vascular
access and preservation of vascular access sites a top priority
for ESKD care.
Hemodialysis vascular access planning must consider
both the type and location of the vascular access, keeping in
mind both the current needs and the future needs of the
patient. Each selection of vascular access (type and location)
should provide the patient with a functional vascular
access that is reliably usable for dialysis with minimal
complications and interventions to allow the patient to
achieve his/her dialysis goals. The vascular access contingency
plan is the plan for vascular access remediation
when the vascular access becomes problematic. The
vascular access succession plan is the thoughtful planning
and preservation for future dialysis access choice(s) when
the current vascular access fails, and it considers the patient’s
ESKD Life-Plan.
For patients expected to have prolonged durations on
HD, a distal-to-proximal approach to AVF creation (if they
are deemed suitable) preferentially using the superficial
veins or consideration of a forearm graft (if deemed not
suitable for a forearm AVF) before upper arm AV access
provides the best opportunity to preserve vessels for future
vascular access sites (Table 3.1). It allows for a sequential
vascular access plan for a prolonged ESKD Life-Plan on HD.
However, it has been recently observed that an unintended
consequence of the enthusiasm for a fistula-first approach
to vascular access has led to an increasing number of upper
arm AV accesses in the United States,84
perhaps with the
sole goal of reaching “fistula targets,” which may inadvertently
and negatively affect a patient’s future vascular
access options. For example, younger individuals who are
expected to have long survival with ESKD might be
disadvantaged by the decision to create bilateral upper arm
Guideline 3. Vascular Access Locations
S46 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
AVF—especially basilic vein transposition—as the first
(failed) and then second options for vascular access. Doing
so would significantly limit their future vascular access
possibilities, leaving them with suboptimal options for the
remainder of their life on HD. Furthermore, failed AV
access or urgent HD starts that require CVC insertion may
later negatively affect vascular access options if the placed
CVC contributes to the limiting effect of central stenosis.
Careful consideration of the site of CVC insertion in such
situations is required. Thus, this KDOQI Work Group has
proposed a sequence of site selections that considers the
patient’s ESKD Life-Plan with a view to individualizing and
optimizing access options.
Much of this KDOQI’s guidance aligns with the previous
KDOQI Guidelines (2.1) that recommended evaluation
of the distal forearm for radiocephalic AVF followed by
brachiocephalic AVF before considering brachiobasilic
transposition AVF or AVG. It considered an AVG as a
bridge to an AVF. The current Guideline promotes
consideration of other variables such as preparation time
available, expected time on dialysis, current and future
modality options (eg, transplant), likelihood of AVF success,
and vascular access contingency and succession plans
for each vascular access type and location selected.
Detailed Justification
One RCT85
and 8 observational studies evaluated different
vascular access locations.86-94
The RCT compared a brachiobasilic
AVF to a brachiocephalic AVF among patients
in whom a previous forearm AVF had failed or a forearm
AVF was not feasible.86
Primary patencies were not
significantly different with a brachiobasilic AVF versus a
brachiocephalic AVF at 1 year (RR, 0.98; 95% CI, 0.84-
1.34) or 3 years (RR, 0.90; 95% CI, 0.73-1.11)
(Supplement 3, Table S11).85
Similarly, secondary patency
was not significantly different with a brachiobasilic AVF
versus a brachiocephalic AVF at 1 year (RR, 1.02; 95% CI,
0.88-1.19) or 3 years (RR, 1.02; 95% CI, 0.80-1.32; P =
0.8) in Koksoy et al85
(Supplement 3, Table S11). Given
these data, the Work Group supports a philosophy to
create the most optimal AVF that would preserve future
sites and allow greatest patient ease and comfort for cannulation
and dialysis.
One observational study compared AVFs placed ipsilateral
to a prior CVC versus contralateral to a prior CVC.93
Secondary patency was significantly lower with an AVF
ipsilateral to a prior CVC versus contralateral to a prior CVC
(Supplement 3, Table S12), leading to the suggestion to
insert a CVC contralateral to the planned AV access, should a
CVC be required. Seven of the observational studies
compared various AVF locations, including radiocephalic,
brachiocephalic, brachiobasilic, or unspecified upper arm or
forearm. Three studies86,87,91
had high risk of bias
(Supplement 3, Table S13)86,87,91
and were not extracted or
used in analysis. The studies used are in Supplement 3,
Table S14.85,88,89,92-94
Due to the poor quality and inconsistent
evidence, we were unable to place it into clinical
context to recommend a stepwise approach to vascular access
creation, leading to suggestions to consider vascular
access type and location that would provide the patient with
functional use, preserving future sites at the discretion of
the clinician after considering the patient’s circumstances,
available suitable vessels, and ESKD Life-Plan.
AVG Locations
If an AVG is the most appropriate type of vascular access, the
evidence does not strongly support a preference of location.
Dixon et al96
compared forearm AVG with upper arm AVG
in a subgroup analysis of an RCT that evaluated the effect of
dipyridamole plus aspirin on AVG patency (n = 508)
(Supplement 3, Table S15). Both primary and cumulative
patencies did not differ by location at 1-year follow-up
(Supplement 3, Table S16a). Primary patency was 70% in
the forearm AVG group and 78% in the upper arm AVG
group. Cumulative graft failure was 33% and 36% for the
forearm AVG and upper arm AVG groups, respectively
(adjusted HR, 1.36; 95% CI, 0.94-1.97). No other studies
met the criteria for inclusion by the ERT.
CVC Locations
Asnoted, inferior AVFoutcomes have been observedifa prior
ipsilateral CVC has been placed.94
However, there are lower
complication risks with right internal jugular CVC insertion
compared with the left side, so this must be considered in
light of the patient’s ESKD Life-Plan and current and future
vascular access needs. One observational study compared
right-versusleft-sidedcatheterplacement98
(409participants
and 532 catheters). Catheter-related infection requiring
removal was significantly higher with left-sided approaches
compared with right-sided approaches (0.33 vs 0.24 per 100
catheter-days; P = 0.012) (Supplement 3, Table S16b).
Decreased blood flow requiring CVC exchange (ie, CVC
dysfunction) was also nonsignificantly higher with left-sided
approaches (0.13 vs 0.08 per 100 catheter-days; P = 0.08)
(Supplement 3, Table S16b). However, these outcomes were modified
based on the positioning of the CVC tip. For CVC tips placed in the
superior vena cava or pericavoatrial junction, CVC dysfunction
and infection were higher for left-sided approaches
Table 3.1. Vessel Location by Distal to Proximal Sites
Vessel Location/
Cannulation
Location AVF AVG
Forearm/
forearm
Snuffbox or distal radiocephalic
forearm radial or ulnar basilic
Forearm loop
Forearm/upper
arm
Proximal radiocephalic, antecubital
vessel-perforator combinations
Upper arm/
upper arm
Brachiocephalic Upper arm
straight
Brachiobasilic Upper arm
loop
Other brachial or basilic
combinations
Abbreviations: AVF, arteriovenous fistula; AVG, arteriovenous graft.
Guideline 3. Vascular Access Locations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S47
compared with right-sided approaches, as noted earlier.
However, for CVC tips placed in the mid- to deep right
atrium, CVC dysfunction and infection were similar for leftcompared
with right-sided approaches. This highlights the
need for proper CVC placement and confirmatory imaging
(Guideline 9).
Tables of studies, evidence quality, and bias are provided
in Supplement 3, Tables S16b and c.
Special Discussions
Surgeons and Other Operators: Practical
Considerations of Choice of Vessels
Where appropriate, consider the use of superficial veins
before deep veins. Recall that venous drainage in the extremity
is from superficial (veins superficial to deep fascia)
to deep venous system (veins deep to deep fascia). Deep
veins tend to converge in a single vein as it approaches the
heart.99
Obliteration or stenoses in the deep veins impair
the availability of more distal access sites. Thus, evaluation
of potential vascular access sites could consider first using
the superficial veins for the outflow. Forearm and upper
arm cephalic and forearm basilic veins are considered superficial
veins.100
The Work Group believed that it is
reasonable to consider a forearm loop graft in the sequence
as a bridge to future AVF when the superficial vein–based
options are exhausted. Importantly, the AVF location
should consider the maturation of the outflow vein,
facilitating future cannulation. An adequate cannulation
vein segment should be long enough to accommodate (1)
needle separation of at least 1 inch (2.54 cm) or 2 finger
widths and (2) rotation of cannulation sites to avoid
aneurysm development. Furthermore, it should be easily
and comfortably accessible for the patient. Having segments
on the underside of the arm can be uncomfortable
or very painful. Segments that are too deep may be challenging
to cannulate without ultrasound guidance, which
may not be readily available and/or may lead to patient
and nursing/technician frustration. Although superficialization
of such deep AVF may be possible, it is
important to note that AVF use for dialysis is typically
delayed due to the need for a planned secondary procedure.
See also the commentary in Guideline 8.
Special Considerations for Internal Jugular and
Femoral Vein Catheterization
Operators and clinicians should be aware of the possibility
of persistent left superior vena cava anomalies and its entailments
when choosing the internal jugular veins for
catheterization.
In select patients and limited circumstances, tunneled cuffed
femoral vein catheterization may be reasonable. For
example, in situations where patients urgently start dialysis
and are not transplant candidates but are in clinical environments
that are conducive to quick dialysis access creation/insertion
(ie, within 1 month), tunneled cuffed
femoral CVC may serve several beneficial purposes. First, it
will preserve central veins to ensure that AV access is feasible
(assuming central veins not previously damaged or stenosed
by other processes). Second, use of femoral vein CVC reminds
patients and providers that CVC is only for temporary
purposes. This strategy is effective only if the facility can
coordinate rapid AV access creation for patients destined for
HD (eg, early cannulation AVG or AVF in a patient with
high likelihood of maturation success) or PD catheter
insertion for patients who have chosen PD. Issues such as
proper placement of the exit site to ensure patient comfort
and dignity must be considered (Fig 3.1). Of note, RCTs,
metanalyses, and systematic reviews have demonstrated
equivalent or superior outcomes with regard to CVC
thrombosis and infection, using tunneled femoral vein CVC.
However, precaution with femoral CVC use, as with any
CVC use, must be taken (Guidelines 20-25).101-103
Implementation Considerations
It is important to reiterate that the primary goal of vascular
access creation and planning is to create a functional vascular
access that can provide reliable prescribed dialysis, with minimal
interventions and complications.15,79
The planning must consider contingency plans for
remediation when the vascular access becomes problematic
and a succession plan for future dialysis access options
Figure 3.1. Placement of femoral vein central venous catheter.
Guideline 3. Vascular Access Locations
S48 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
when the vascular access eventually fails. This applies to all
populations in need of dialysis access, including CKD patients
with a failing transplant, PD patients who require
transition to HD, pediatric CKD patients, other established
CKD patients, or patients needing an urgent start to dialysis.
A proactive approach to the pediatric CKD patient
with failing eGFR is imperative to avoid CVC placement for
HD initiation. This means allowing adequate maturation
time to enable the AV access to be usable on the day of HD
initiation—typically several months of lead time for AVF
creation and a few weeks for an AVG placement. CVC
avoidance for elective HD is achievable with adherence to
the ESKD Life-Plan. It is imperative that health care providers
communicate the ESKD Life-Plan and vascular access
creation, contingency, and succession plans to provide
continuity in KRT and dialysis access care.
Future Research
 It is known that medium-sized peripheral arteries
(radial and ulnar) of >2 mm can develop AVF to support
adequate dialysis.104
Future research can inform on
the impact of both larger and smaller vessels used for AV
access creation. For example, for larger arteries, identify
what characteristics are associated with a greater risk of
high flow–associated problems. For smaller vessels,
determine what characteristics allow for adequate AVF
maturation and use.
 Weigh the potential options for vascular access type and
location, as discussed; to determine and study more
accurate patient-specific estimates of the predicted
duration of HD and predicted probability of AVF
maturation and consider the results when choosing
access type and location.
 More prospective research to determine whether
endoAVF creation can result in a clinically durable and
cost-effective AV access compared with traditional surgical
AV access creation and maintenance.
Guideline 4. AV Access Types and Materials
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Novel AV Access Types and Materials
4.1 KDOQI suggests that the choice of material for an
AVG should be based on the nephrologist’s or
operator’s discretion and best clinical judgment
since the current evidence does not demonstrate
that one graft material or modification thereof is
associated with improved outcomes in terms of
patency or complications. (Conditional Recommendation,
Low Quality of Evidence)
4.2 KDOQI considers it reasonable to use early cannulation
grafts as a CVC-sparing strategy in
appropriate patients, considering their ESKD LifePlan.
(Expert Opinion)
Rationale/Background
Effective hemodialysis requires a suitable access for the
withdrawal and return of blood. The ideal hemodialysis
access should provide adequate flow rates to sustain prescribed
dialysis; be easy to access/cannulate, cost effective,
and acceptable to patients; and be associated with excellent
long-term patency and minimal complications. A mature,
functional autogenous AV access or AVF may be the most
ideal access, although not all patients have suitable veins
for an AVF, and not all of the veins mature sufficiently for
cannulation, thereby negating their potential advantages.
Furthermore, in the culture of patient-centered care, an
AVF may not always be the appropriate access, given individual
circumstances. Acceptable AV access can be
created by using a variety of AVGs, including prosthetic,
biologic, and autogenous materials. Expanded polytetrafluoroethylene
(PTFE) has been the most commonly used
graft material since its original description and has served
as the comparator or criterion standard for numerous
randomized trials. A variety of other prosthetic graft materials
are commercially available, although none have
proven to be superior to PTFE in terms of the patency or
complications. Similarly, a variety of graft modifications
have been made to improve AVG performance, including
changes in wall thickness, surface modifications, diameter
changes, and external support, but none have proven superior
to the standard wall 6-mm PTFE graft. The use of
autogenous and biological grafts had largely been abandoned
with the introduction of PTFE, although some
limited recent evidence suggests that nonautogenous
saphenous vein and bovine carotid artery biological grafts
may be associated with fewer infectious complications and
improved patency, respectively. The current KDOQI
statements on this topic are consistent with the previous
2006 KDOQI guideline.
Detailed Justification
PTFE has been the most widely used prosthetic material for
AVGs since its introduction more than 40 years ago.105
There have been a variety of RCTs and observational
studies (Supplement 3, Table S17) evaluating various AVG
materials and configurations. For example, there have
been comparisons of tetrafluoroethylene (Dacron,
Dupont)106,107
or polyurethane108,109
to PTFE, although
none have proven superior in terms of patency or
complication rates. Similarly, the brand of PTFE does not
appear to make a difference in terms of outcome.110,111
Guideline 4. AV Access Types and Materials
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S49
There have been numerous modifications of the prosthetic
AVGs, predominantly PTFE, to improve patency and reduce
complications, although none of these modifications have
been proven in RCTs to be consistently superior to the standard
wall 6-mm PTFE AVG. These modifications have
included the thickness of the AVG material (ie, thin-wall
PTFE),112
the elasticity of the AVG material (ie, stretch
PTFE),113
externalreinforcement(eg,externalrings),tapered
AVG diameter (ie, 4- to 7-mm taper PTFE, 6- to 8-mm taper
PTFE),114,115
addition of a cuff to the venous end of the
AVG,116,117
surface modification with heparin,118
and
modification of the external surface.119
Notably, Polo et al115
reported that the 6- to 8-mm tapered PTFE upper arm AVGs
had better primary and primary-assisted patency rates than
the 6-mm grafts without an increased incidence of AV access
steal, although the patient population was limited to nondiabetic
patients aged <71 years. Dammers et al114
reported no
difference in the patency or incidence of steal symptoms
between the 4- to 7-mm tapered and 6-mm PTFE AVGs. The
4- to 7-mm tapered grafts may theoretically reduce the
incidence of steal symptoms due to the smaller diameter and
resultant lower flow rates; however, the flow rates through
the tapered grafts in their study were actually greater than the
nontapered ones. The RCTs examining the benefit of a venous
outflow cuff have been contradictory, with Sorom et al117
reporting improved patency and increased flow rates for the
cuffed AVGs. Of note, none of the cuffed AVGs failed as a
result of a venous outflow stenosis. Data from a more recent
study by Ko et al116
found that primary patency was not
significantly different with cuffed versus noncuffed graft at 1
or 2 years (63% vs 50% at 1 year; RR, 1.23; 95% CI, 0.71-
2.13; 45% vs 32% at 2 years; RR, 1.56; 95% CI, 0.39-6.19)
(Supplement 3, Table S18).
Surface treatment of AVG with heparin affords a theoretical
advantage in terms of thrombosis and patency,
although the available evidence failed to demonstrate any
significant differences.118
Specifically, the patency (1-year
primary patency with heparin-bonded [14%] vs standard
AVG [12%] at 1 year [RR, 1.10; 95% CI, 0.50-2.44]; 2year
secondary patency with heparin-bonded AVG [83%]
vs standard AVG [73%] at 2 years [RR, 1.14; 95% CI, 0.96-
1.34]), and complications rates were comparable between
groups.
In terms of timing of graft cannulation, Aitken et al120
reported that early cannulation PTFE grafts (ie, modification
of the middle layer) were associated with reduced
bacteremia and mortality when compared with tunneled
dialysis CVC. A systematic review by Al Shakarchi et al121
suggested that the newer-generation early cannulation
grafts can be safely cannulated without detriment and were
associated with comparable patency and complications
with standard-wall PTFE, although the number of studies
that made up the review was limited.
The HeRO graft is a nontraditional vascular access that
comprises a hybrid PTFE graft–catheter system that represents
a variation of the prosthetic graft modifications
outlined earlier. A recent RCT comparing the HeRO graft
to standard-wall PTFE demonstrated no difference in
patency (primary patency, 35% HeRO vs 28% standard
AVGs; RR, 1.25; 95% CI, 0.54-2.89 and secondary patency
66% HeRO vs 56% standard AVGs at 1 year; RR, 1.19; 95%
CI, 0.75-1.89) mortality (HeRO [2%] vs standard graft
[0%]; RR, 1.19; 95% CI, 0.44-3.23; risk difference, 0.02;
95% CI, -0.02 to 0.06), or complications.122
Notably, this
trial was designed to compare the safety and efficacy of the
HeRO graft in a cohort of patients without central vein
occlusions or stenosis. However, the HeRO graft may have
its greatest applicability in this subset of patients.
The role of autogenous and nonautogenous biological
AVGs has evolved. Their use was largely abandoned with
the introduction of PTFE (described earlier). Two recent
trials suggest that biologic AVGs may confer some
advantage, although the sample sizes were relatively small
(<60 patients). Kennealey et al123
reported that the bovine
carotid artery AVG might be associated with improved
outcome. Notably, the primary patency (bovine carotid
artery AVG [61%] vs PTFE AVG [10%] at 1 year; RD, 51%;
95% CI, 39-61; P = 0.006 by Kaplan-Meier analysis;
however, the numbers at risk at each time point was not
indicated), thrombosis rates (0.34/patient-year versus
PTFE AVG [0.77/patient-year] [RR, 0.44; 95% CI, 0.29-
0.67; P = 0.01 by Poisson regression analysis]), and reintervention
rates (1.45/patient-year versus PTFE AVG
[1.99/patient-year] [RR, 0.73; 95% CI, 0.58-0.91]) were
significantly lower when compared with PTFE AVG,
although there were no differences in the secondary
patency (64% vs a PTFE graft [59%] at 2 years; P = NS) or
other complications. Mousavi et al124
reported that the
infectious complication rates with nonautogenous human
saphenous vein AVG were lower than for PTFE, although
there were no differences in patency.
The saphenous and femoral veins have both been used
as autogenous AVG materials.125,126
The saphenous vein is
relatively thick walled and does not usually dilate when
used for an AVF, similar to the cephalic or basilic veins
traditionally used for upper extremity autogenous access.
Furthermore, the saphenous vein diameter is not usually
large enough to meet the minimal criteria for effective
dialysis (ie, ≥4 mm; flow rate, ≥500 mL/min).127
The
mean diameter of the femoral vein is sufficient for effective
cannulation (ie, 7 mm), and the length of the femoralpopliteal
segment is adequate for brachial-axillary access,
although its use in this configuration is associated
with a modest incidence of wound complications and AV
access steal.125,128
AvarietyofnoveltechniquesandAVGs arecurrentlyunder
investigation, including a totally percutaneous or endovascular
arteriovenous graft, fistula,129
and a bioengineered graft
composed of human tissues.130
Although RCTs have not yet
reported their efficacy, they may play a role in the future.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S18 through S20.
Guideline 4. AV Access Types and Materials
S50 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Special Discussions
The Work Group discussed the need for the guidelines to
be updated in an iterative fashion to allow for new hemodialysis
access options and the ability to properly
evaluate them and incorporate worthy options in future
guidelines.
Implementation Considerations
See Guideline 1.
Monitoring and Evaluation
See Guidelines 11, 12, and 14-19.
Future Research
 Further define the optimal nonautogenous graft material
for an AV access.
 Further validate the benefits identified for the current
biologic grafts.
 Further develop novel techniques and graft materials for
the creation of autogenous and nonautogenous AV access.
Guideline 5. CVC Configuration and Materials
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statement: CVC Configuration and Materials
5.1 KDOQI suggests that the choice of tunneled HD
CVC type and design be based on the clinician’s
discretion and best clinical judgment. (Conditional
Recommendation, Low Quality of Evidence)
Rationale/Background
Identifying the type of CVC with the lowest complication
rate is important for patients who are dependent on CVC
for chronic HD—whether for short-term or long-term use.
However, RCTs comparing various CVC types and designs
do not consistently demonstrate, with moderate- or highquality
evidence, significant differences in primary-assisted
patency, CRBSI, or thrombosis rates. Catheter types evaluated
in these clinical trials include the following:
 Tesio-Cath twin catheter system versus LifeCath Twin
catheter system (MedComp)131
 Palindrome Symmetric Tip versus HemoStar Long-Term
CVCs (staggered tips) (Medtronic)132
 Palindrome Symmetric Tip versus Medcomp (step-tip)
CVCs133
 Ash Split (split-tip) (MedComp) versus PermCath
(Medtronic) or Optiflow (step-tip) (Bard Access Systems)
catheters134,135
Detailed Justification
The following summarizes key evidence-based CVC
comparisons:
Twin Catheter Systems: Tesio Versus LifeCath
Twin Tunneled CVCs
One RCT (n = 80) compared the Tesio-Cath (ovoid
cuff) versus the LifeCath Twin (cuboidal cuff); both
CVC types have 2 free-floating lumens and were placed
in the right internal jugular vein. Study follow-up was
12 months.131
There was no significant difference in
CVC survival (92% for the Tesio-Cath group vs 86% for
the LifeCath Twin group) or CRBSI (0.40/1000 CVC
days [Tesio group] and 0.51/1000 CVC days [LifeCath
Twin group]; P = 0.7). Rates of hospitalization for
infection and CVC-related mechanical complications
were higher in the LifeCath Twin group compared with
the Tesio-Cath group (0.94 vs 0.24 per 1,000 CVC days,
respectively; P = 0.02). This was associated with the
greater need for urokinase infusions in the LifeCath
Twin group (0.51 per 1,000 CVC days) versus none in
the Tesio-Cath group.
Palindrome Symmetric Tipped Versus HemoStar
Staggered Tipped Tunneled CVC
A number of studies found no significant difference in
primary assisted patency, CRBSI, or thrombosis rates when
comparing Palindrome symmetric tipped versus HemoStar
staggered tipped tunneled CVC as follows: 1 RCT (302
CVCs inserted in 239 participants)132
reported no statistically
significant difference in infection and thrombosisfree
CVC survival (after censoring for CVC
design–unrelated removal) or CRBSI (0.24 and 0.10 per
1,000 CVC days [HR, 2.26; 95% CI, 0.44-11.96]) in the
Palindrome and HemoStar CVC groups, respectively).
Although rates of thrombosis or CVC removal due to
thrombosis did not differ between groups, the need for a
urokinase infusion was lower for the Palindrome group
versus the HemoStar group: 17 versus 35 (HR, 0.58; 95%
CI, 0.49-0.68).
Urokinase is rarely used in the United States today. It is
unknown whether the decreased urokinase use in Palindrome
CVCs would also apply with other more commonly
used thrombolytic agents, such as recombinant tissue
plasminogen activator (TPA).
Palindrome Symmetric Tip Versus Medcomp StepTip
Catheter
One RCT (n = 97) of 2 months’ duration showed that CVC
survival at 2 months was significantly higher in the symmetric
tip group compared with the step-tip group, 91%
Guideline 5. CVC Configuration and Materials
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S51
versus 69% (P = 0.02).133
For the indication of decreased
blood flow rate, fewer CVCs were removed in the symmetric
tip CVC group compared with the step-tip CVC
group (6% vs 22%; P = 0. 04).
Ash Split-Tip Catheter and Permcath or Optiflow
Step-Tip Catheters
There were 2 RCTs.134,135
One study compared the Ash
Split with the PermCath catheter (N = 69).134
CVC survival
at 12 months after censoring for recovery of kidney
function AVF creation, peritoneal dialysis, and transplantation
was higher in the PermCath group compared
with the Ash Split group (74% vs 49%) with no difference
between groups in CVC removal due to sepsis, rates of
infection, or CVC occlusion requiring removal. The other
study compared the Ash Split to the Optiflow catheter (n =
132).135
In this study, overall CVC survival at 180 days was
higher in the Ash Split CVC (75%) compared with the
Optiflow CVC (55%; P = 0.02).
Study details and evidence quality are provided in
Supplement 3, Tables S21-S29.
Special Discussions
 The ERT did not find significant evidence of benefit of
coated catheters, and therefore, these were not included
in this Guideline. However, the Work Group believed it
was a potential area of future research.
Future Research
 More clinical studies are needed to identify the ideal
hemodialysis CVC that meets the criteria of long survival
times, low CVC complication rates (dysfunction and
CRBSI), and potentially lower patient complication rates
(vascular stenosis and thrombosis). Scientific advances
will need to focus on vascular biology and the design of
biocompatible CVC materials to minimize complications
of hemodialysis CVC for the select patients who
are not candidates for an AVF or AVG.
 Future CVC designs, materials and coatings should also
focus on the impact of CVC on the development of
central stenosis, infection risk, vessel injury, and/or
thrombosis.
 All CVC design studies should report results using
consistent definitions and outcomes.
Guideline 6. Timing, Preparation, and Planning
for Creation/Insertion of Dialysis Access
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Education on ESKD Modalities and
Dialysis Access
6.1 KDOQI considers it reasonable for adult and pediatric
patients with an eGFR <30 mL/min/1.73 m2
(CKD G4) with progressive decline in kidney function,
to be educated on all modalities of kidney replacement therapy
(KRT) options, including transplantation, so that
timely referral can be made for the appropriate
modality and creation of a functional dialysis access,
if necessary. (Expert Opinion)
Note: For pediatric patients, calculate eGFR by Schwartz formula.
6.2 KDOQI considers it reasonable for adult and pediatric
patients with a kidney transplant with an
eGFR < 30 mL/min/1.73 m2
(CKD G4) with progressive
decline in kidney function, to be educated on
all modalities of KRT options, including potential retransplantation,
so that timely referral can be
made for the appropriate modality and creation of
a functional dialysis access, if necessary. A rereview
of the patient’s ESKD Life-Plan should
occur. (Expert Opinion)
Note: For pediatric patients, calculate eGFR by Schwartz formula.
6.3 KDOQI considers it reasonable for PD patients with
complications refractory to therapy and/or with
circumstances that make PD less conducive than HD
to be educated on all kidney transplant and HD options,
so that timely referral can be made for the
appropriate modality preparation and creation of a
functional dialysis access, if necessary. A re-review of
the patient’s ESKD Life-Plan should occur. (Expert
Opinion)
Note: See Special Discussions.
6.4 KDOQI considers it reasonable and important to
ensure that the predetermined dialysis access is usable
to provide the prescribed dialysis when the
patient is ready to initiate the planned dialysis (eg, an
AV access is mature and ready for cannulation for
HD). (Expert Opinion)
6.5 KDOQI considers it reasonable that in patients
who have unplanned or urgent dialysis starts with
a CVC, the ESKD Life-Plan is established with a
dialysis access plan within 30 days of dialysis start.
(Expert Opinion)
Statements: Referral for AV Access
In some facilities, referral of the patient for assessment by
the vascular access team/surgeon for appropriate dialysis
access is a different process than referral for the actual
creation/insertion. However, for simplicity, the Guideline
recommendations have been combined, keeping in mind
variable timeframes between assessment for and creation
of vascular access.
Guideline 6. Timing, Preparation, and Planning for Creation/Insertion of Dialysis Access
S52 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Nondialysis CKD Patients
6.6 KDOQI considers it reasonable that in nondialysis
CKD patients with progressive decline in kidney
function, referral for dialysis access assessment and
subsequent creation should occur when eGFR is 15-
20 mL/min/1.73 m2
. Earlier referral should occur
in patients with unstable and/or rapid rates of eGFR
decline (eg, >10 mL/min/year). (Expert Opinion)
Note: Nondialysis CKD patients include patients who have a failing
transplant.
Hemodialysis Patients
6.7 KDOQI considers it reasonable that in HD patients
with recurrent vascular access problems, prompt
referral for assessment and creation of a new AV
access should be made to allow adequate time for
specialist consult and follow-up, as well as
possible AV access failure and correction, and
should consider individual patient circumstances
and competing risk of death. (Expert Opinion)
Note: Recurrent vascular access problems include recurrent need for
CVC use and/or >3 corrective interventions/6 months.
When PD Is the Modality of Choice
6.8 KDOQI considers it reasonable and ideal to place a
PD catheter at least 2 weeks before the anticipated
need of the PD treatments. (Expert Opinion)
6.9 KDOQI considers it reasonable for an urgent PD
catheter to be placed for immediate PD as necessary
under the direction and care of experienced
personnel in conducive environments. (Expert
Opinion)
Rationale/Background
Timely referral for appropriate KRT modality education
and choice is necessary to allow adequate time for the
preparation, creation, and use of a functional dialysis
access when it is needed at dialysis initiation. It is the
first of many important steps required to attain “the
right access, in the right patient, at the right time, for
the right reasons,” one of the guiding principles of the
Guideline.
These 2019 Guideline statements regarding modality
and vascular access education are almost identical to the
2006 KDOQI guideline,13
although this Guideline emphasizes
the Expert Opinion basis due to the paucity of
rigorous evidence to support recommendations.
Key differences in the statements for the timing of education
and referral for vascular access creation/insertion
include using referral criteria that do not depend solely on
GFR criteria and recognizing the challenges of creating
vascular access based on a predicted time of dialysis start. A
range of patient populations that may need vascular access
is also recognized.
Detailed Justification
Appropriate and well-balanced education and preparation
are required for patients to choose the most suitable
KRT modality and corresponding access, suitable
for each patient’s own circumstances (see Guideline 1
on ESKD Life-Plan).
It has become increasingly evident that despite clinicians’
best efforts, predicting when a patient will initiate
dialysis is challenging at best—and mostly inaccurate.
Several studies have demonstrated that neither GFR alone
nor a time duration before dialysis start is reliable, and
using such criteria to base vascular access decisions leads to
variable results.136
Patient and process-of-care factors play
contributing roles of varying degrees, depending on the
different circumstances associated with each combination
of interactions.
This Guideline attempted to find a balance between
achieving a functional AV access at dialysis initiation
with potential unnecessary procedures that may occur
if a predialysis patient’s kidney function does not
decline or due to the competing risk of death. The
competing risk of transplant or transfer to PD should
be less of an issue if appropriate and timely modality
education and preparation occur, corresponding to the
patient’s ESKD Life-Plan. Given the lack of prospective
studies evaluating different GFR thresholds for vascular
access creation, a well-conducted simulation study
supports an eGFR referral of 15-20 mL/min/
1.73m2
.137
Studies have also demonstrated increasing
postcreation procedure rates with longer time away
from starting dialysis beyond 6 to 9 months, with no
greater proportion of patients initiating dialysis with
an AVF.138
Such a time frame makes intuitive clinical
sense given the time now required to ensure AVF
maturation and usability, with an average time to
cannulation of 132 days in the United States (USRDS
2017, chapter 3)—for AVF that do not fail.139
The
corresponding AVF that failed to mature was 35.9%. A
6- to 9-month time frame from dialysis initiation
would allow time to create a new AV access to be used
for dialysis start should the first one fail; the challenge,
again, is being able to predict the start time. Thus, it is
critical to allow time for surgical referral and creation,
plan for risk of AV access failure and correction, and
consider trajectory of progression (if predialysis) or
CVC exposure time (if on dialysis), along with the
competing risk of death when referring for AV access
creation.
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S53
Special Discussions
Patients transferring to HD, after failing PD, frequently
start HD with a CVC.140
Special efforts to examine the
reasons for this and reduce CVC use in this population are
required.
Suggested indications for the creation/insertion of a
vascular access in PD patients (Table 6.1) are provided and
based on Expert Opinion.
Future Research
 Validation of suggested criteria using both eGFR criteria
and progressive decline in kidney function is required
 Validation of criteria to refer PD patients for HD vascular
access
 Use of prediction equations (eg, the Kidney Failure Risk
Equation) to assist with timing of access–does this really
help?141
 Develop and validate approaches to reduce potential
damage to central and peripheral vessels by providers
throughout the health care system while waiting for AV
access creation.
 Investigate in which patients the decline of eGFR appears
to slow or halt after AVF creation, and why this
may occur
Statement: Vessel Preservation
6.10 KDOQI considers it reasonable to protect all
central and peripheral arteries and veins from
damage whenever possible, including the avoidance
of peripherally inserted catheters and unnecessary
venipunctures, for patients on dialysis
or with CKD where dialysis access is expected in
the future (CKD G3 -G5). (Expert Opinion)
Note: Other scenarios where vessel (artery or vein) damage may occur
that should be avoided include (1) radial artery access for
coronary interventions and 2) venous cardiovascular implantable
electronic devices; alternatives such as epicardial/leadless pacing
should be considered whenever possible.
Rationale/Background
Central and peripheral vessel damage may contribute to
CVC dysfunction and limit future options for AV access
creation and usability in CKD and ESKD patients. Due to
the growing age and comorbidities of this population, the
risk of and exposure to potentially vessel-damaging conditions
and interventions are high. For example, venipuncture
itself and infusion of sclerosing medications
though peripheral intravenous catheters may result in
damage and/or thrombosis of peripheral vein segments
that may later be used for AV access creation or CVC
insertion. In addition, catheterization of central veins for
non-HD requirements such as internal jugular and subclavian
lines for acute and chronic care, transvenous
pacemakers, and defibrillators are associated with stenosis
or loss of central vein patency. Central stenosis is a serious
complication that may prohibit successful AV access creation,
maturation, or use. PICCs are known to damage veins
with subsequent thrombosis in many cases. There is also
the risk of clot propagation into the central veins. Loss of
these veins can have a dramatic impact on patient
morbidity and mortality with loss of current and future
HD vascular access sites.142-144
Patients should be educated
regarding these risks and encouraged to advocate for their
own vessel protection, along with the nephrology community’s
support. An informative website on saving veins
can be found at www.saveyourvein.org, which serves as an
example of a public platform educating on the importance
of saving veins. It can be used by patients and professionals.
Indeed, caregivers involved in the delivery of
care to CKD stage 4/5 patients should be educated
regarding the implications of venous and arterial access
use, and institutional policies directed toward addressing
these concerns are strongly suggested.
Detailed Justification
A case-control study (N = 120) demonstrated that the
prior placement of a PICC was associated with a subsequent
lower frequency of AVF use144
(odds ratio, 3.2; P <
0.001,) even after adjustment for patient sex, artery and
vein diameters, and prior CVC insertion. An observational
study using USRDS data found that of 6,487 HD patients
with PICCs placed within 2 years before and after AV access
creation were independently associated with lower
likelihoods of transition to any working AV access.142
One study examining the presence of central vein stenosis
(CVS) in association with PICCs reported a 7% rate of
overall CVS.145
However, this is likely an underestimation
of the true incidence of CVS associated with PICCs, because
the study was limited to patients undergoing serial extremity
venography. In a prospective study examining
Table 6.1. Suggested Indications for Creation/Insertion of a Vascular
Access in Peritoneal Dialysis Patients
 Recurrent peritonitis, especially if due to poor connection technique
(Gram-positive) or bowel leak (mixed Gram-negative)
 Ultrafiltration failure, especially in the presence of oliguria or anuria
and persistent volume overload
 Decline in physical status considered to be the result of underdialysis
(adherence issues or loss of residual kidney function)
B Note: This is a relative indication and should not be construed as
implying that loss of RKF is itself an indication for vascular access
creation.
B Caution: The patient nonadherent to PD may very well be nonadherent
to HD and vascular access creation.
 Change in status of the patient, such that self-dialysis is no longer
feasible
B For example, intercurrent event, such as stroke, death, or other
loss of a caregiver
 Significant noninfectious complication
B For example, recurrent hernias, dialysate leaks including
hydrothorax
Guideline 6. Timing, Preparation, and Planning for Creation/Insertion of Dialysis Access
S54 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
thrombosis associated with PICC placement, all patients
underwent ultrasound examination of the arm at 28 days
after PICC insertion or at time of PICC removal and found
an overall thrombosis rate of 71.9% (partial or complete
obliteration of vessel lumen).146
Unfortunately, the national
effort to reduce the use of PICCs among CKD and
ESKD patients has not achieved its objective. Notably,
McGill et al147
reported from their urban teaching hospital
that >30% of patients with CKD have had a PICC and that
>50% were placed in their nondominant arm.
Angiographic comparisons of stenosis rates between
subclavian and jugular HD CVC insertions found that both
were associated with stenosis, with 42% of subclavian
veins stenosed after CVC insertion.148
Finally, the use of a
CVC (including PICCs and catheters inserted at the subclavian
and jugular veins) was found to be associated with
a 14-fold increased risk of an upper extremity DVT.149
Vein loss may be extrapolated from DVT formation.
In a consensus statement regarding cardiovascular
implantable devices in CKD and ESKD patients, it was
noted that such patients derive a reduced survival benefit
from implantable cardioverter defibrillator treatment
compared with patients with normal kidney function, with
a 2.7-fold higher risk of mortality.150
With regard to CVS,
64% of patients developed stenosis.151
Options to avoid
upper body central veins include femoral vein placement
(with its own risks of infradiaphragmatic venous damage),
epicardial placement, subcutaneous implantable cardioverter
defibrillator placement, leadless pacers, and
possibly wearable defibrillators.152,153
Finally, with regard to radial artery access for cardiac
interventions, a meta-analysis of the literature noted a
radial artery occlusion rate of <1% to 33%. The conclusion
was that radial artery occlusion was common.154
Given the
fact that radial artery patency is integral to future radiocephalic
AVF creation, femoral arterial access for coronary
interventions should be strongly considered.
Special Discussions
 Alternative options to PICCs are needed—potential options
suggested were pediatric internal jugular vein
catheters/small bore catheter; however, whether or not
their use translates into less vessel damage and CVS is
unknown.
 The “Choosing Wisely” campaign should be fully
supported in CKD/ESKD patients to “save the vein” and
avoid PICCs whenever possible.
Implementation Considerations
 Strategies to avoid PICCs and vessel damage, such as
venipuncture in the back of the wrist and use of smallbore
internal jugular CVCs should be studied
 Avoid PICCs for <7 days of infusion—use a peripheral
intravenous line, preferably on the back of the hand
 Consider femoral venous access for central vein access
 Continuous quality improvement within/across
institutions
 PICC placement in CKD patients in hospital requires
approval by nephrology department
Monitoring and Evaluation
 Use of PICCs only when there are no other options
Future Research
 Feasibility and use of other options for blood access
 Radial access impact on future VA creation
 Midline catheter insertion effect on future VA creation
 Does use of small-bore internal jugular CVC reduce
central venous stenosis?
 Determine if use of small-bore internal jugular CVCs
instead of PICCs is practically feasible and effective for
patient care
 Rigorously evaluate the impact of radial artery access for
cardiovascular and other procedural interventions on
the creation and outcomes of AV access for HD
Statements: Multidisciplinary Team Approach
6.11 KDOQI considers it reasonable to educate on,
coordinate, and manage all aspects of dialysis
access using a multidisciplinary team within the
resource capacities and feasibilities of each facility.
(Expert Opinion)
6.12 There is inadequate evidence for KDOQI to make
a recommendation on the use of a multidisciplinary
team to reduce the rate of CVC use or
increase the use of AVF.
Rationale/Background
As described previously (Guideline 1), the ESKD Life-Plan
is a strategy for living with ESKD, ideally formulated by the
patient and a multidisciplinary team (coordinated CKD
management team). A patient-centered approach to HD
vascular access considers multiple aspects of a patient’s
needs and dialysis access eligibility, specifically considering
the patient’s current medical situation, current and
future life goals, preferences, social support, functional
status, and logistic and other practical feasibilities. For the
purposes of dialysis access, this team should include but is
not limited to the following professionals and supportive
members: nephrologist, access surgeon, radiologist, nurse,
social worker, and patient family member or other
supporter.
Placement of any dialysis access, but particularly an AV
access, requires education of the patient and family, as well
as coordination of visits around timely surgical consultation
and follow-up visits. Given the limited ability of individual
nephrologists to attend to the multiple and
complex aspects of vascular access care, most kidney care
programs have established multidisciplinary vascular access
Guideline 6. Timing, Preparation, and Planning for Creation/Insertion of Dialysis Access
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S55
teams.155-157
The multidisciplinary VA team ensures
timely referral for vascular access when appropriate,
tracking, and monitoring patients’ vascular accesses for
complications and outcomes. Often central to the team is a
vascular access coordinator (VAC) who coordinates and/or
schedules the patient for procedures. In addition, the
vascular access coordinator is key to educating patients on
the risks and benefits of each vascular access choice,
addressing any patient concerns, and facilitating appropriate
use of the vascular access.158
Detailed Justification
Although the multidisciplinary team approach appears
ideal, the majority of studies of multidisciplinary team care
were at high risk of bias.159-167
Only 1 study that evaluated
a care coordinator,168
1 study evaluating multidisciplinary
care,165
and 1 study evaluating patient education169
were
extracted and analyzed (Supplement 3, Table S30).
Multidisciplinary Care
Wilson et al165
(N = 3,636) analyzed patients starting HD in
the DaVita system with follow-up for 360 days. An Incident
Management of Patient, Actions Centered on Treatment
(IMPACT) program for patients before and early in dialysis
was instituted at selected clinics to manage predialysis and
early dialysis issues, including initiating HD with an AV
access. The multidisciplinary team included a nephrologist,
nurses, dietitians, social workers, and clinical care providers
and involved structured intake, referral services, patient
education, patient management checklists and timelines,
and monitoring outcomes. Usual care also included patient
education and other interventions, but not in a formalized
manner. Patients in the IMPACT program were propensitymatched
to patients receiving usual care in a 1:2 ratio, and
treatment groups were well balanced for baseline characteristics.
Use of an AVF or AVG versus a CVC was not
significantly different among IMPACT patients (50%)
versus usual-care patients (47%) (RR, 1.06; 95% CI, 0.99-
1.14) at 90 days.165
However, use of an AVF or AVG versus a
CVC was significantly higher among IMPACT patients
(63%) versus usual-care patients (48%) (RR, 1.31; 95% CI,
1.22-1.41) at 360 days.165
The success of the multidisciplinary team has historically
been measured by increasing the rate of use of the
AVF.170-173
However, there are a number of other
important outcomes, including the rate of VA-related
procedures and complications. Recently, Gill et al174
performed
an observational study of vascular access outcomes
in the first year of HD treatment before (2004-2005, preteam
period) and after implementation of an access team
(2006-2008, early team period; 2009-2011, late team
period). Access team implementation did not affect the
probability of CVC-free use of the AVF (OR, 0.87; 95% CI,
0.52-1.43, for the early and OR, 0.89; 95% CI, 0.52-1.53
for the late-team period). Patients underwent an average of
4 to 5 total access-related procedures during the first year
of HD, with higher rates in women and in people with
comorbidities. CVC-related procedure rates were similar
before and after team implementation; relative to the preteam
period, AVF-related procedure rates were 40% (20%-
60%) and 30% (10%-50%) higher in the early-team and
late-team periods, respectively. One difficulty in interpreting
the results of this study is that concurrent with the
implementation of the access team was the widespread
implementation of Fistula First policies in the study centers.
The use of AVG was very low (<1%) in the centers
involved in the study. Although the CVC rates were
similar, the rates of procedures increased in AVFs of
women and those with greater comorbidities, factors
associated with poor AVF maturation and outcomes. It is
unclear if results would have differed if those high-risk
patients had received AVG instead. This highlights the
need to evaluate the use of multidisciplinary vascular access
team to help patients delineate an appropriate ESKD
Life-Plan with the corresponding appropriate vascular access,
including evaluation of feasibility for AVF.
Vascular Access Coordinator
Data on the true impact of a VAC for improving VA outcomes
is lacking. Sixty percent of HD programs reported
having at least 1 VAC in a 2013 Dialysis Outcomes and
Practice Patterns Study survey of 72 US sites, but they did
not report whether an access team was present.170,174
The
percentage of patients using an AVF or a CVC did not differ
across facilities with or without at least 1 VAC. The percentage
of use of one type of vascular access or another is
insufficient for evaluating the usefulness of a VAC. It is not
only the percent use that matters but for those using a
particular vascular access, it matters whether or not that
use is appropriate, safe, and provides patient satisfaction
and support for their dialysis to help them achieve their
own goals. Having a VAC has been shown to increase the
odds of successful unassisted AVF maturation, the ideal
form of AVF maturation. Indeed, VACs have the expertise,
skills, and capacity to build relationships with patients and
multiple team members to educate, coordinate, guide, and
manage vascular access for the patient175,176
—typically
much better than solely physicians and surgeons. For
example, having a dedicated vascular access nurse or
coordinator to assist physicians and staff with management
of CVC-related infections has been reported to reduce CVC
treatment failure rates and death from sepsis.177-179
However, further research is required to generate more
specific evidence to support vascular outcomes that can be
attributable to the work of VACs.
Future Research
Further research is needed to identify new strategies to
deliver optimal, personalized, and patient-centered
vascular access care. Data on the true benefits of a multidisciplinary
vascular access team are limited. The success of
a multidisciplinary vascular access team is dependent on
Guideline 6. Timing, Preparation, and Planning for Creation/Insertion of Dialysis Access
S56 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
the defined outcome measure. If it is increasing the use of
AVFs, there are conflicting data from observational studies
using different compositions of teams and roles of the
team members. Additionally, these types of studies require
accurate information regarding vascular access use across a
patient’s ESKD lifespan, which is challenging and requires
high-quality data assessing time periods of vascular access
use with and without a CVC.
Currently, there are no data on the benefit of multidisciplinary
teams on patient trust and confidence in
making dialysis access–related decisions, in their quality of
life or satisfaction with their dialysis access. Futures studies
may also determine the impact of a VAC and multidisciplinary
teams on health care spending, which may or may
not show benefit by shifting care from physicians to
lower-cost providers. This may also enhance patient
engagement and promote shared decision making. These
important outcome measures should be evaluated in future
studies.
Guideline 7. Patient and Vessel Examinations:
Preparatory Considerations
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Patient Clinical Examination
7.1 KDOQI recommends that a physical examination
focused on vascular anatomy be the basis for the
initial assessment and planning of vascular access
creation. (Conditional Recommendation, Very Low Quality
of Evidence)
7.2 KDOQI considers it reasonable to have greater
emphasis on and more training in preoperative
clinical examination to assess patients and their
vessels to determine the type and location of their
vascular access. (Expert Opinion)
Rationale/Background
The most appropriate AV access creation requires careful
preoperative evaluation. Among many factors, the characteristics
of the patient’s vascular anatomy, cardiovascular
system, and life expectancy will influence the ideal type
and location of access (Figs 1.1-1.6). The decision to
create an AVF after a thorough preoperative evaluation is
aimed at reducing the primary failure rate and improving
the cumulative patency rates with few or no additional
interventions. The common techniques used in clinical
practice include clinical examination and duplex ultrasound
evaluation, as previously recommended in the 2006
KDOQI guideline (1.4.1, 1.4.2, and 1.4.3).13
A detailed
history and physical examination focused on evaluating the
vascular anatomy and cardiovascular system, as outlined in
Table 7.1, remains relevant. The belief that vessel mapping
with duplex ultrasonography is better than clinical examination
remains contentious. Preoperative vessel mapping
to evaluate the arteries and veins using duplex ultrasonography
has been recommended in the past based solely
on Expert Opinion. The potential benefits outlined were
selection of vessel based on luminal size and
Table 7.1. Focused Preoperative Physical Examination for Vascular
Access Planning and Creation
Consideration Relevance
Physical examination of arterial
system
Character of peripheral
pulses
Allen test
Bilateral upper extremity
blood pressures
Physical examination of venous
system
Evaluation for edema
Assessment of arm sizes
comparability
Examination for collateral
veins
Evaluation of veins:
Augmented palpation
Examination for evidence of
prior central or peripheral
venous catheterization
Examination for evidence of
arm, chest, or neck surgery/
trauma
Cardiovascular evaluation
Examination for evidence of
heart failure
 An adequate arterial system is
needed for AV access; the quality
of the arterial system will influence
the choice of AV access site.
 Abnormal arterial flow pattern to
the hand may contraindicate the
creation of a snuffbox or
radiocephalic AVF.
 Equality or discrepancies of blood
pressure values inform the
suitability of arterial inflow and
access in the upper extremities.
 Edema indicates venous outflow
problems that may limit usefulness
of the associated potential
vascular access site or extremity
for vascular access placement.
 Differential arm size may indicate
inadequate veins or venous
obstruction that may influence
success of AV access created and
choice of vascular access site.
 Collateral veins are indicative of
venous obstruction, as discussed.
 Palpation augmented by
tourniquet ± warm stimulus (eg,
water) will inform venous
characteristics (eg, distensibility).
Selective venous mapping may be
helpful (Guideline Statement 7.3
and Table 7.2)
 Use of CVCs is associated with
central venous stenosis; previous
placement of venous catheters,
pacemakers, etc may have
damaged target vasculature
necessary for vascular access
(Guideline Statement 6.10).
 Vascular damage associated with
previous surgery or trauma may
limit access sites (Guideline
Statement 6.10).
 Poor cardiac output or ejection
fraction may affect success of
AV access created (eg, low
output may increase risk of
maturation failure).
 AV accesses may alter cardiac
output.
Abbreviations: AV, arteriovenous; CVC, central venous catheter.
Guideline 7. Patient and Vessel Examinations: Preparatory Considerations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S57
distensibility with manual occlusion of blood flow, thus
ensuring that the most appropriate vessel is used to
create a successful AV access. However, duplex ultrasonography
has several disadvantages that include
measurement errors due to operator skill and circumstances
(eg, the skills and interpretation of a lab technician
vs the surgeon creating the access may differ, the
condition of the patient as cold/dehydrated vs warm/
well hydrated may influence results, environment of
outpatient clinic vs intraoperative ultrasonography may
be important, etc), patient inconvenience, higher costs
to health care system, and delays in creating AV access.
Detailed Justification
Two RCTs and 1 observational study compared preoperative
vessel mapping by duplex ultrasonography to
physical examination for assessment of AVF creation.180-
182
The majority of patients were predialysis, with hypertension
and diabetes. The median age was 66 years,
more than half were white, and 60% were men. The
minimum follow-up was 6 months after AVF creation.
There was no statically significant difference in AVF
primary failure (21.5% vs 31.1%; RR, 0.69; 95% CI,
0.45-1.08]) or primary patency (62.5% vs 52.5%; RR,
1.19; 95% CI, 0.97-1.45) between the 2 groups.
However, secondary patency was greater with preoperative
ultrasound compared with physical examination
alone (81.6% vs 65.2%; RR, 1.18; 95% CI, 1.01-1.37).
There was no difference in those with vessel mapping
compared with physical examination for frequency of
postoperative interventions (20.1% vs 22.9%; RR, 0.88;
95% CI, 0.36-2.15); unnecessary creation before dialysis
start, transplant, or death (12.1% vs 11.9%; RR
1.02; 95% CI, 0.49-2.13); or mortality (7.5% vs 4.7%;
RR, 1.58; 95% CI, 0.53-4.70). The studies were not
powered to assess the potential harm, especially to
detect the number of unnecessary AV access creations
(Supplement 3, Table S31).
Statements: Vessel Mapping for Vascular Access
7.3 KDOQI suggests selective preoperative ultrasound
in patients at high risk of AV access failure
(Table 7.2) rather than routine vascular mapping
in all patients (Conditional Recommendation, Low Quality
of Evidence).
7.4 KDOQI considers it reasonable to use various imaging
studies as needed to evaluate the suitability
of vessels for AV access creation such as ultrasonography
for peripheral vessels (including intraoperative
ultrasound) and venography for
suspected central vein occlusion, while considering
the patient’s clinical circumstances and residual
kidney function. (Expert Opinion)
Rationale/Background
Given the lack of high-quality evidence of preoperative
mapping on AVF outcomes over thorough clinical evaluation,
there may be utility in selective use of preoperative
vessel mapping. Such selective use could be applied to
patients considered to be at high risk of AVF failure
(Table 7.2), those at risk of or with a history of vessel
damage or central stenosis, or those for whom a proper
physical examination is not possible or feasible (eg,
morbidly obese patients).
Justification
One RCT compared selective versus routine preoperative
vessel mapping by duplex ultrasonography for AVF
creation (n = 77).183
The majority of patients were
predialysis with hypertension and diabetes, and their
median age was 65 years old. There was no statistically
significant difference in AVF primary failure rate at 90day
follow-up in those who had selective versus routine
vessel mapping (36.0% vs 21.1%; RR, 1.71. 95% CI,
0.81-3.59), postoperative interventions (5.3% vs 5.1%;
RR, 1.03; 95% CI, 0.15-6.92) or total complications
(12.8% vs 2.6%; RR, 4.87; 95% CI, 0.60-39.79). Primary
and secondary patency were not evaluated. The
study was too small to properly detect harms, and effect
modification was not assessed (Supplement 3,
Tables S32 and S33).
Given this set of evidence, the Work Group could not
endorse vessel mapping in all patients but wanted to
ensure that it could be supported in patients deemed at
high risk while supporting the need for further study. The
impact of preoperative vessel mapping may be very
important and may not be apparent from the studies
conducted to date; it is unclear whether the impact of
preparative mapping conducted by an independent
Table 7.2. Examples of Risk Factors For Which Vessel Mapping May Be
Beneficial
Clinical Problem Risk Factors
Fistula failure Elderly age, female, comorbidities (eg,
peripheral vascular disease, coronary artery
disease), small pediatric patients
Peripheral vessel
damage
Ipsilateral: PICC insertion, other iatrogenic
(eg, venipuncture), self-inflicted (eg, IVDU),
disease states (eg, vasculitis), radial artery
harvesting for CABG
Central venous
stenosis
Multiple CVCs; prolonged CVC duration;
cardiac implantable electronic device; PICC;
surgery or trauma to neck, chest, upper extremity
Limitations to physical
examination
Morbid obesity, suboptimal conditions (eg,
patient dehydrated or vasoconstricted), poor
skin integrity, patient refusal
Note: When central venous stenosis is suspected, ultrasound has low
sensitivity for detecting central vein stenosis, and venogram should be
performed when possible to confirm and locate lesions.
Abbreviations: CABG, coronary artery bypass graft; CVC, central venous
catheter; IVDU, intravenous drug use; PICC, peripherally inserted catheter
central.
Guideline 7. Patient and Vessel Examinations: Preparatory Considerations
S58 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
imaging facility separate from the operator has the same
impact as preoperative mapping conducted by the operator
who will be creating the AV access. This is an area that
needs to be clarified through research.
Statements: Optimal Vessel Size of Artery and Vein
for AV Access Creation
7.5 KDOQI considers it reasonable that while there is
no minimum diameter threshold to create an AVF,
arteries and veins of <2 mm in diameter should
undergo careful evaluation for feasibility and
quality to create a functioning AVF. (Expert Opinion)
7.6 KDOQI considers it reasonable to evaluate multiple
characteristics of vessel quality for AVF creation
(size, distensibility, flow, etc). (Expert Opinion)
Rationale/Justification
The previously suggested vein diameter of 2.5 mm and
arterial diameter of 2.0 mm have not been validated. The
threshold was included in the KDOQI Clinical Practice
Guideline for Vascular Access as an Expert Opinion based
on a single study by Silva et al in 1998.184
Despite the
routine use of duplex ultrasound, the primary failure rate
in the multicenter Dialysis Access Consortium Fistula study
was reported to be as high as 60%.31
Our current
knowledge is limited to retrospective single-center
studies.185-187
The studies evaluating vessel size are
inconsistent in their reporting regarding the timing (immediate
before surgery in the operating room vs imaging
suite), distensibility with tourniquet, operator skills
(technician vs surgeon), and location (radiocephalic vs
brachiocephalic).
The limited clinical evidence meeting guideline criteria
for ERT review are summarized:
Allon et al,28
in a single-center study, evaluated over
a 17-month period the effect of routine preoperative
mapping on the types of vascular access placed and their
outcomes. The minimum vein diameter of >2.5 mm
and arterial diameter of >2.0 mm for AVF creation and
vein diameter of >4.0 mm for AVG creation were
implemented. The study did not report their outcomes
based on different tertiles of vessel size. Overall,
compared with historical controls, the study reported an
increment in AVF creation rate from 34% to 64%, with
the greatest improvement in women and diabetic patients.
The overall increment in the usability of AVF to
support dialysis from the historical cohort was statistically
insignificant (46% to 54%; P = 0.34). However,
there was substantial increase in the usability of forearm
AVFs, although it was not statistically significant (34%
to 54%; P = 0.06).
Dageforde et al188
reported on a retrospective study of
158 patients (mean age, 54 years; diabetes, 56%; body
mass index, 32 kg/m2
) with brachiocephalic or
brachiobasilic AVF. The study cohort was divided into
quartiles based on the vein diameter, with a vein diameter
in the lowest group of <2.7 mm and in the highest group
of >4.1 mm. Patients with minimum vein diameter of
>3.4 mm had a higher maturation rate compared with
those with vein diameter of <3.2 mm (79% vs 90%) and
6-, 12- and 24- month patency of 77%, 55%, and 49% vs
90%, 67%, and 58%, respectively.
The variability in reported parameters limits the clinical
evidence necessary to make any recommendations on
minimal lumen size. Furthermore, it may be important to
consider variables other than vessel size; for example,
distensibility (defined as increase in internal vein diameter
with proximal compression), arterial wall thickness, and
resistance index to reactive hyperemia were used in a study
of 116 patients by Malvorh.189
Primary patency rate in
patients with increment in internal venous diameter (from
0.226 cm ± 0.063 to 0.335 cm ± 0.115) was 80.2%
compared with 19.2% among patients with internal
venous diameter increment from 0.219 cm ± 0.097 to
0.245 cm ± 0.126). The study also evaluated internal
arterial diameter, baseline arterial blood flow, and resistance
index with reactive hyperemia with forearm AVFs.
The group with higher maturity had an internal arterial
diameter of 0.264 cm ± 0.065 vs 0.162 cm ± 0.066,
baseline blood flow of 54.5 mL/min ± 2.81 vs 24.11 mL/
min ± 16.81 and resistance index at hyperemia of 0.50 ±
0.13 versus 0.70 ± 0.17. However, the usability was not
reported.
Future Research and Educational Needs
There is a paucity of training in vascular access physical
examination for the preparation or use of vascular access.
The Work Group members believed that there should be a
much greater emphasis on and more training in preoperative
clinical examination to assess patients and their vessels
to determine the type and location of their vascular
access.
The impact of preoperative vessel mapping may be very
important and may not be apparent from the studies
conducted to date; it is unclear whether the impact of
preparative mapping conducted by an independent imaging
facility separate from the operator has the same impact
as preoperative mapping conducted by the operator who
will be creating the AV access. This is an area that needs to
be clarified through research.
Guideline 8. AV Access Creation
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Guideline 8. AV Access Creation
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S59
Statement: Pre-Creation Infection Prevention
8.1 KDOQI considers it reasonable to conduct a careful
history and physical exam by the operator and
managing team prior to AV access creation to
identify infection risks that should first be
managed before proceeding with AV access creation
(eg, dental infection, osteomyelitis, etc).
(Expert Opinion)
Statement: Use of Anesthesia for AV Access
Creation
8.2 KDOQI suggests that the choice of anesthesia for
AVF creation should be based on the operator’s
discretion and best clinical judgment, as current
evidence shows no difference between regional
block or local anesthesia in terms of AVF usability,
patency, interventions, or patient experience.
(Conditional Recommendation, Low-Moderate Level of
Evidence)
Rationale/Background
A majority of AV access creation procedures require subcutaneous
dissection and minimal deep dissection in a
circumscribed area of the extremity. Conventionally, these
procedures have been performed using local anesthesia
and intravenous sedation to increase patient ease. More
significant procedures that require extensive tissue dissection
such as aneurysm repair or superficialization are
usually performed under general anesthesia or regional
blocks, based on the operator’s discretion.190
Both regional
and general anesthetic have the potential for inducing
vasodilation by altering the vascular autonomic tone191
;
the resultant larger vessels (up to 25%)192
may improve
operative ease. Such observations have prompted investigators
to evaluate whether the method (type and
location) of anesthesia helps to increase AV access creation
rates, AV access patency, AVF maturation, patient satisfaction,
and operator ease. This topic is new to the current
NKF-KDOQI VA Guideline.
Detailed Justification
The success of AVF maturation after creation31,193
may be
associated with the vein diameter used for anastomosis.104
It is hypothesized that dilation of veins with increased
caliber and flow might facilitate and increase AVF crea-
tion,194,195
particularly distal AVF creation. However, it is
uncertain whether anesthetic-induced vein dilation and
AVF creation are associated with improved AVF maturation
and use. In particular, regional block anesthesia has a
propensity to dilate superficial veins and increase the blood
flow to the limb during the intraoperative and immediate
postoperative period.196
It has been suggested that the
resultant increased vein dilation and flow might lead to
more distal AV access site selection and creation and that
the increased flow in the perioperative phase might increase
AVF maturation.194,195
The greater availability of duplex ultrasonography has
increased the ease, safety, and efficacy of administering
regional (supraclavicular and infraclavicular) block for
surgical procedures performed in the upper limb.197
Six RCTs and 3 observational studies compared the
effectiveness and harms of different anesthesia techniques
on AV access outcomes192,198-200
; however, 1 RCT and all
3 observational studies were excluded due to high risk of
bias. The evaluated studies showed no difference in AV
access patency or failure, patient satisfaction, and complications
between groups receiving regional anesthetic
using different techniques compared with those receiving
local anesthetic during radiocephalic or brachiocephalic
AVF creation.
Yildirim et al201
(N = 100) compared a stellate ganglion
block versus local anesthesia for patients undergoing
radiocephalic AVF creation. Patients were followed up
until their AVF was sufficiently mature for cannulation.
Successful cannulation was not significantly different
with a stellate ganglion block versus local anesthesia
(RR, 1.58; 95% CI, 0.996-2.52). However, the mean
maturation time was significantly shorter with stellate
ganglion block (mean, 41.4 days) versus local anesthesia
(mean, 77.1 days) (mean difference, -36 days; 95% CI,
-41 to -31).
Three RCTs compared brachial plexus block versus local
anesthesia.192,199,200
In patients receiving radiocephalic
AVF, pooled analysis showed no significant difference in
AV access patency, failure, or complications (Supplement
3, Table S34). In the study by Aitken et al,198
the ability
to use the AVF was significantly higher with a brachial
plexus block versus local anesthesia among patients who
had a radiocephalic AVF created (RR: 1.83; 95% CI, 1.07-
3.12) (Supplement 3, Table S35). For those receiving
brachiocephalic AVF, the type of anesthesia did not differ
in AVF patency, need for secondary interventions, ability
to cannulate the AVF, or patient satisfaction.
Reasonably good procedural safety for different
regional block techniques performed with ultrasound
guidance has been shown.197
However, regional blocks
are also associated with small but significant risks of
short- and long-term complications.202
Thus, the choice
of anesthesia technique for AVF creation should be based
on institutional experience, operative technique, and
patient characteristics to optimize successful AVF creation
(Supplement 3, Tables S34-S38).
Special Discussions
The Work Group discussed that creating distal AVF, when
appropriate, helps preserve more proximal sites. Vasodilation
caused by regional anesthesia may provide an opportunity
to identify vessels that were missed or deemed
not suitable due to small size during initial evaluation. It is
worthwhile to investigate if there is a subgroup of patients
Guideline 8. AV Access Creation
S60 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
who may benefit from the use of regional anesthetic.
Central venous stenosis is an important cause for long-term
failure of AVF. Any irritation in and around these veins
precipitates development of this problem over time. Longterm
effects of regional anesthetic that is infiltrated in the
neurovascular bundle that contains the ipsilateral central
vein are not known.
Future Research
 Identify a patient population who may benefit from the
use of regional anesthesia.
 Evaluate the long-term effect of regional anesthesia on
central veins.
Statement: AV Access Anastomotic Configuration
and Apposition Methods
8.3 KDOQI considers it reasonable that the choice of
anastomotic configuration and apposition method
(eg, vascular clips, sutures) for AVF creation be
based on the operator’s discretion and best clinical
judgment, as there is insufficient evidence to prefer
one configuration or apposition method over
another. (Expert Opinion)
Rationale/Background
Anastomotic configuration is one of many factors considered
for its potential influence on AV access primary failure and
outcomes. An acute increase in blood flow and a configurational
change in the outflow vein are 2 permanent changes
that follow AVF creation.203
Studies have demonstrated that
wall shear stress, caused by the altered flow pattern after AV
access creation, may lead to venous neointimal hyperpla-
sia,204,205
which isassociated with juxta-anastomotic stenosis
(JAS). JAS is consistently seen at the AVG-vein anastomosis of
an AVG and AV anastomosis in an AVF206,207
and is associated
with AV access thrombosis and AV access maturation failure.4
An optimal anastomotic configuration or apposition method
might mitigate adverse flow patterns and shear stress204,208
of
the created AV access but may also have unintended consequences,
such as venous hypertension.
Detailed Justification
Studies have evaluated anastomosis techniques and tools
for AVF creation.209-211
Mozaffar et al210
compared sideto-side
with end-vein–to–side-artery anastomosis. Primary
AVF failure at 6 months was not significantly
different with side-to-side (20%) versus end-to-side
anastomosis (17%) (RR, 1.20; 95% CI, 0.41-3.51)
(Supplement 3 Tables S39-S42).
A French observational study by Sadaghianloo et al211
compared radial artery deviation and reimplantation (RADAR)
technique (n = 53) with historical control standard
end-vein–to–side-artery anastomosis (n = 73). Primary
AVF patency at 6 months was significantly better with the
RADAR technique (93%) versus end-vein–to–side-artery
anastomosis (52%) (RR, 1.81; 95% CI, 1.29-2.55). Other
outcomes, including secondary AVF patency and interventions,
also favored the RADAR technique.
In terms of apposition methods, similar outcomes have
been found when anastomotic vascular clips have been
compared with sutures (see detailed discussion in Guideline
Statement 8.4, AV Access Anastomotic Suture Technique).
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S39-S42.
Special Discussions
The Work Group discussed ERT recommendations related
to the RADAR technique. The technique necessitates radial
artery transection and is an end-artery–to–side-vein anastomosis.
Although bidirectional flow in the cephalic vein
may be a reason for increased patency similar to side-toside
AVF, it also poses the risk for development of
segmental venous hypertension in the long term; thus, the
main reason for selective use of end-to-side anastomosis
over side-to-side anastomosis. Transection of the radial
artery is a future ischemic risk for patients for whom the
procedure fails. Although the RADAR study showed benefits
in the short term, the long-term outcome remains to
be seen.211,212
Computational fluid dynamics (CFD)
modeling with similar arterial configuration in end-to-end
anastomosis has suggested the possibility of developing
arterial stenosis related to flow stress.213,214
Although the ERT found low to moderate quality of
evidence for end-artery–to–side-vein anastomosis over endvein–to–side-artery
anastomosis for AVF creation for better
primary patency and need for intervention, the Work Group
had reservations. The Work Group believed that, in addition
to methodologic issues (nongeneralizability [ie, only radiocephalics
were evaluated in the study], limited short-term
follow-up, etc), clinical concerns such as potential loss of
the artery for future vascular access, potential for venous
hypertension, and hand ischemia hampered the Work
Group’s enthusiasm for this technique.
Implementation Considerations
Avoid: Excessive Depth in AV Access Creation
Regardless of anastomotic technique, AV accesses that lie
too deep relative to the surface of the skin can lead to
problems with cannulation. This scenario typically arises
for obese patients with brachiocephalic AVFs but can
occur with the other AV access types and configurations
depending on the distribution of fat in the forearm for
the radiocephalic AVF and the depth at which the various
AVGs and brachiobasilic AVFs are tunneled. This concern
is more relevant for the nonmaturing AV access,
although it can present later in the life cycle of the AV
access.
There are a variety of open surgical techniques to
elevate, or superficialize, the AVF relative to the surface of
the skin.215-219
An incision can be made over the course of
Guideline 8. AV Access Creation
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S61
the AVF, typically the outflow vein for a brachiocephalic
AVF, and the vein can be elevated by re-approximating the
underlying subcutaneous tissue. Bronder et al215
reported
an extensive 7-year experience with 296 consecutive patients
with excellent long-term results. The subcutaneous
tissue overlying the AVF can be resected, effectively
resulting in elevation of the AVF by decreasing the distance
between the skin and the AVF. Alternatively, the vein can
be transposed or rerouted rather than simply elevated,
thereby reducing the likelihood of the vein being exposed
if the wound were to breakdown. Bourquelot et al216
have
described making a series of transverse incisions over the
course of the conduit and undermining the skin to facilitate
resecting the excess subcutaneous tissue, while others
have described using suction lipectomy.220,221
Future Research
The preponderance of stenosis in specific anatomic locations
suggests that local hemodynamics plays a significant role in
its development. The availability of better imaging techniques
and CFD provides an opportunity to model hemodynamics
and shear stress patterns.222
Areas of bends and
curves tend to have maximum shear stress gradient that
predisposes to VNH.213,222
Hull et al223
studied side-to-side
CFD models and found a configuration, called the piggyback
Straight Line Onlay Technique (pSLOT), to have more uniform wall
shear stress patterns compared with several other angles.
Future rigorous study of this and other techniques based on
hemodynamic parameters will be insightful to help limit the
development of JAS and consequent stenosis, with the hope
of improving AV access longevity.
 Study of hemodynamics (flow, shear stress) as a causative
factor for AVF dysfunction outcomes (eg, outflow
vein stenosis, JAS)
 Develop AV access–specific CFD modeling
 Clinical evaluation of different anastomotic configurations—identify
stress zones and mitigate or avoid
them (prevention of stenosis)
 A piggyback straight-line onlay technique has been
described but was excluded from ERT appraisal due to
the high risk of bias209
; further rigorous study of this
technique may be insightful
 Further rigorous research and long-term follow-up of
RADAR technique
Statement: AV Access Anastomotic Suture
Technique
8.4 KDOQI considers it reasonable that the choice of
suture technique for AV access creation should be
based on the operator’s discretion and best clinical
judgment, as there is insufficient evidence that any
anastomotic suture technique is advantageous in
terms of AV access patency or complications. (Expert
Opinion)
Rationale/Background
Creation of vascular access is associated with a significant risk
of primary failure.31
Suture techniques are one of the many
factors thathavebeen studied toevaluatetheirinfluence onthe
surgical outcome of AV access creation. Vessel apposition by
suturing can be performed in a continuous or an interrupted
fashion. Studies have shown hemodynamic advantage for
interrupted anastomosis in the presence of pulsatile flow.224
Due to difficulties in execution and lack of adequate devices
available to perform interrupted anastomosis, continuous
suturing is the most prevalent anastomotic technique.
Two new devices225,226
have been evaluated and may
help surgeons to use interrupted suturing to perform
vascular access anastomosis.
Detailed Justification
Continuous versus interrupted anastomosis have different
hemodynamic profile and compliance patterns at the paraanastomotic
site of small vessel anastomosis.224
The current
literature does not provide clarity on the effect of this
altered hemodynamic and compliance on long-term AV
access outcomes. A recent RCT (n = 78) reported improved
primary patency for a partially interrupted anastomosis in
radiocephalic AVF but no difference in functional
patency227
compared with continuous sutures. Another
retrospective study compared the outcomes of continuous
versus interrupted anastomosis in 334 procedures performed
in a large cohort of veteran patients and observed an
equivalent outcome.228
A larger multicenter (17 centers)
retrospective study reported the long-term performance of
398 AVF (199 clips, 199 sutures) and 740 AVG (401 clips,
344 sutures). Improvements in bleeding complications,
primary patency, and cumulative patency were associated
with clipped anastomosis in AVF that were patent and used,
and in an intention-to-treat analysis, improved patency was
also associated with clipped anastomosis in AVG.
Two RCTs assessed the comparative effectiveness and
harms of using continuous versus interrupted suture
techniques in AVF. Zeebregts et al229
compared the
outcome of VCS clips (Tyco Health/Auto Suture Company)
versus 6-0 Prolene (Johnson & Johnson) sutures in
98 patients followed up to 2 years. Walker 230
compared
the U-clip device (Medtronic) with continuous 6-0 Prolene
suture (Johnson & Johnson) for anastomosis in 31
patients. Pooled data from these 2 trials failed to show a
statistically significant difference between continuous
versus interrupted techniques; the primary AVF patency at
6 months for clips was 71% and for sutures was 72% (RR,
0.98; 95% CI, 0.73-1.32).229,230
Secondary patency at 6
months was also not statistically different between clips
(86%) and sutures (69%) (RR, 1.25; 95% CI, 0.96-1.64).
Special Discussions
Although interrupted anastomoses appear to have a better
hemodynamic profile at the anastomotic site, studies have
Guideline 8. AV Access Creation
S62 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
failed to show a significant impact on AV access outcome.
One retrospective study231
with a large number of AVF
anastomosis (n = 1,345) with a long-term follow-up
period (2 years) found significant patency advantage for
clips (AnastoClips), suggesting that the beneficial effect of
a better hemodynamic profile is possibly small.
The theoretical disadvantage of interrupted anastomosis
is the potential for the anastomosis to expand with time,
possibly leading to mega fistula. Although this was not
demonstrated as a major factor in coarctation repair in
cardiac surgery,232
it may be possible in AVF construction
on larger vessels that have a higher propensity of developing
flow-related problems. Further study of anastomotic
techniques is required.
Statements: Use of Operator-Assisted Maneuvers
for AV Access Maturation
8.5 KDOQI does not suggest the use of allogenic
endothelial implants to improve AVF maturation,
patency, or clinical usability or to improve AVG
graft patency or reduce thrombosis. (Conditional
Recommendation, Very Low Quality of Evidence)
8.6 KDOQI does not suggest the use of pancreatic
elastase to improve the patency and clinical use of
AVF or AVG. (Conditional Recommendation, Moderate
Quality of Evidence)
8.7 KDOQI considers it reasonable to have a careful
individualized approach to operator-enhanced
(surgical or endovascular) maneuvers during AV
access creation to facilitate AV access maturation,
based on the operator’s best clinical judgment and
expertise. (Expert Opinion)
Rationale/Background
AVF maturation failure and AVG thrombosis remain major
clinical problems for hemodialysis patients. Unfortunately,
20% to 60% of AVFs created fail to mature successfully for
dialysis use.77,233
Thrombosis accounts for almost 80% of
AVG failures31,234-236
due to an underlying stenosis at the
venous anastomosis.237-239
At present there are few, if any,
effective therapies to enhance AVF maturation and reduce
AVG stenosis and thrombosis. Pharmacologic therapies to
assist AVF maturation were not addressed in the 2006
KDOQI guideline.13
Since the 2006 KDOQI guideline,
there have been several RCTs evaluating novel biological
therapies to assist AVF maturation and prevent AVG
thrombosis.
Detailed Justification
The role of adjunctive nonpharmaceutical treatment for
AVF and AVG creation specifically focuses on allogeneic
endothelial cell implants and pancreatic elastase type I
(Supplement 3, Tables S43-S46).
Nonpharmaceutical Biologics to Enhance
Maturation
Allogenic Endothelial Cell Implants in AVF240,241
. Data
from Conte et al240
include 65 maintenance HD patients
needing AVF (n = 31) or AVG (n = 34) from combined
phase 1 (allogeneic endothelial cell implants [AEC] safety
trial) and phase 2 (RCT of AEC vs placebo sponges in a 2:1
ratio) studies. Patients treated with AEC received 2 Vascugel
sponges containing human endothelial cells suspended
in gelatin medium placed adjacent to the venous
outflow vein and anastomosis, with some patients
receiving a third sponge for placement next to the arterial
anastomosis. Primary AVF patency was not statistically
different with AEC (60%) compared with placebo (62%)
at 24 weeks (RR, 0.97; 95% CI, 0.52-1.83).240
There were
no thrombosis events for either the AEC or placebo
groups.240
Local wound infections and need for intervention
to correct a complication were not significantly
different with AEC (4%) versus placebo (0%) (RD, -0.04;
95% CI, -0.20 to 0.13)240
(Supplement 3, Tables S43-S45
and S52).
Allogenic Endothelial Cell Implants in AVG240
. In the
study by Conte et al,240
all patients with AVG (n = 34) had
2 Vascugel sponges placed adjacent to the venous anastomosis
and outflow vein and were followed up for 24
weeks. Phase 2 AVG patients (n = 30) received a third
sponge adjacent to the arterial anastomosis, for a total of 3
implanted sponges. There were no differences in thrombosis
or patency between those receiving AEC or placebo.
Thrombosis at 30 days was 9% in AEC versus 18% in
placebo (RR, 0.48; 95% CI, 0.08-2.96), and primary AVG
patency at 24 weeks was 38% in the Vascugel group
compared with 23% in the placebo group (RR, 1.44; 95%
CI, 0.48-4.27). Local wound infection, thrombosis, and
need for intervention to correct a complication at 30 days
showed ≤2 events for either treatment arm (Supplement 3,
Tabled S46-S48 and S53).
Pancreatic Elastase Type 1 in AVF. Hye et al242
and
Peden et al243
(n = 229) randomized participants with AVF
to pancreatic elastase type 1 (PRT-201) or placebo and followed
them for 1 year (Supplement 3, Table S49). Data were
available in 188 participants for this detailed justification.
The drug was administered directly to the inflow artery,
anastomosis, and outflow vein during surgery, over the
course of 10 minutes immediately after AVF creation. Primary
AVF failure at 2 weeks243
and secondary AVF patency
was not significantly different between 2 two groups.242
Unassisted AVF maturation, defined as maturation with no
prior procedure to restore or maintain patency, at 3 months
was higher with PRT-201 (68%) versus placebo (46%) (RR,
1.48; 95% CI, 1.02-2.15).242
However, hemodynamically
significant lumen stenosis at 3 months was not statistically
different (RR, 0.93; 95% CI, 0.19-3.43).
Inapooledanalysisofthe2trials,primaryAVFpatencyat1
year was not statistically different with PRT-201 versus pla-
cebo(RR,1.21;95%CI,0.87-1.68).242,243
At1year,primary
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S63
AVF patency, the ability to use the AVF (59% for PRT-201 vs
53% for placebo; RR, 1.11; 95% CI, 0.82-1.51),242
and
thrombosis of the AVF were not statistically different (RR,
0.86; 95% CI, 0.31-2.38).242,243
Neither trial showed differences
in any reported harm (stenosis, thrombosis, hypoesthesia,
steal syndrome, or need for intervention)
(Supplement 3, Tables S50 and S51).
Pancreatic Elastase Type 1 in AVG244
. Dwivedi et al244
enrolled 89 patients with AVG and followed them for 6
months. There were 9 study groups grouped by dose levels
(low, medium, high). Pancreatic elastase type I (PRT-201)
was administered as a series of drops directly to the graftvein
anastomosis and adjacent outflow vein over the course
of 10 minutes immediately after AVG creation. At 6
months, AVG thrombosis (42% for PRT-201 vs 46% for
placebo (RR, 0.90; 95% CI, 0.48-1.67) and venous stenosis
(42% for PRT-201 vs 32% for placebo; RR, 1.30;
95% CI, 0.63-2.65) was not different between groups.244
At 1 year, primary AVG patency was not statistically
different between the PRT-201 (range of 17%-21%,
depending on dose) and placebo groups (19%) at all dose
levels. Secondary AVG patency (range of 59%-71%,
depending on dose) was also not significantly different.244
Rates of thrombosis, stenosis, and need for intervention to
correct a complication at 12 months were not significantly
different between groups.
To summarize, 2 RCTs evaluated device or topical therapies
that were delivered intraoperatively after AV access
creation: pancreatic elastase and allogenic endothelial cells.
These therapies are currently not commercially available for
use because they are in phase 3 studies. Moreover, the
current data from these studies do not suggest benefit at this
time in AVF or AVG (Supplement 3, Tables S46-S48).
Intraoperative Devices and Operator-Enhanced
Intraoperative Maneuvers
The OptiFlow anastomotic connection device implanted at
the time of AVF creation has been evaluated in single-arm
studies with comparison with historical control groups
showing similar unassisted AVF maturation rates.245,246
The Optiflow device has not been studied in phase 3
studies and is not commercially available.
Other Surgical Maneuvers
There is very little literature in the area of operatorenhanced
(surgery) maneuvers for AV access maturation
(Guideline Statements 8.5 and 8.6). Whether a 1-stage
versus 2-stage basilic vein transposition is “more beneficial”
when creating an upper arm AVF is a common
clinical question at the time of AVF creation. Only observational
studies are available to address this question, and
these largely do not show a benefit of one technique versus
the other.247,248
Further studies comparing these 2 techniques
will be necessary before recommendations can be
made. Until this issue is resolved, an individualized
approach is suggested.
Intraoperative Endovascular Maneuvers
There has been 1 observational study evaluating the role of
intraoperative primary balloon angioplasty as a technique
to upgrade small-diameter veins during AVF creation in
combination with sequential BAM.249
That study reported
a >90% use in this center with primary balloon angio-
plasty.249
However, it did not have a comparator group
and did not report the number of interventions required to
maintain patency after AVF use, and it was also nonrandomized.
Primary balloon angioplasty with BAM warrants
further scrutiny before further adoption as standard
practice.
Special Discussions
The Work Group discussed the clinical trials challenges of
intraoperative maneuvers to assist AVF maturation (eg,
pancreatic elastase and allogenic endothelial implants,
among others) but acknowledged the need to develop
drugs, devices, and/or strategies to facilitate AVF maturation
and use. BAM was discussed, but the literature was not
extracted due to the limited evidence in this area of
intraoperative maneuvers for AVF maturation.
Implementation Considerations
None of these therapeutics are available for use at present
because the phase 3 studies were terminated before
completion and/or they are currently being evaluated in
ongoing phase 3 studies, and/or the therapy was ultimately
found to be ineffective.
Future Research
 The role of the Fistula Assist device in AVF maturation is
currently in early-phase studies and may play a role in
AVF maturation. No formal data are available regarding
this technology.
 The role of BAM needs to be studied further in the
setting of RCTs.
 One-stage versus 2-stage basilic vein transpositions need
to be studied further in the setting of RCTs.
Guideline 9. CVC Insertion
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Techniques and Other Considerations
for Placement
9.1 KDOQI recommends the use of image-guided CVC
insertions to improve success of insertions. (Conditional
Recommendation, Moderate Quality of Evidence)
Guideline 8. AV Access Creation
S64 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
9.2 KDOQI considers it reasonable that if fluoroscopy
is not used to insert a tunnelled CVC, alternative
imaging is used to ensure that the CVC tip has been
correctly placed. (Expert Opinion)
Rationale/Background
CVCs were traditionally placed by using anatomic landmarks
including vessel pulsation and were typically
inserted in the internal jugular vein (right side preferred
over left side) or the femoral vein (for short term use).
More recently, image-guided placement of CVCs by both
fluoroscopic and ultrasound imaging have been assessed
and used. The advantages to image-guided insertion of
CVCs by trained individuals are increased successful
insertion and reduced complication rates. The main complications
include hematomas and inadvertent arterial
puncture.
The current 2019 NKF KDOQI Clinical Practice Guideline
concurs with the prior 2006 KDOQI guideline for vascular
access that recommended that CVC insertion should be
performed in centers where ultrasound guidance and fluoroscopy
are available. Ultrasound guidance should be used
for all tunneled, cuffed CVC insertions to minimize insertion
complications such as inadvertent arterial cannulation.
Furthermore, fluoroscopic localization of the catheter tip
was also encouraged to allow for ideal CVC tip location for
attainment of maximal hemodialysis blood flow.13
Detailed Justification
Successful placement of a CVC requires attainment of the
proper location within the vascular system and sufficient
HD blood flow rates to achieve prescribed adequate dialysis.
Imaging allows the trained operator to localize the
target vein and its surrounding structures, thereby
detecting any variant anatomy and ensuring patency
(because intraluminal thrombosis is not uncommon).250
Because the anatomic relationship of the right internal
jugular vein to the common carotid artery can vary, ultrasound
guidance for CVC insertion may reduce the
likelihood of inadvertent arterial puncture.251,252
The 2019 KDOQI recommendations are primarily based
on the greater quality of evidence that image-guided
placement of CVC results in a higher likelihood of successful
insertion, with weaker evidence that it reduces
complications (as will be discussed). In this section, imaging
refers to fluoroscopic and ultrasound guidance.
A single-center RCT (N = 110) compared the success of
ultrasound-guided versus traditional insertion (using
anatomic landmarks without ultrasonography) of uncuffed
femoral vein CVCs and accounted for physician experience,
comparing those with <6 years of experience with
those with >6 years of experience. The success rate
(defined as insertion of the CVC after no more than 3
attempts) was significantly higher with ultrasound (98% vs
80%; P = 0.002), as was success on the first attempt (86%
vs 55%; P < 0.001).253
Significantly fewer attempts were
required to achieve catheterization with ultrasound (mean
of 1.16 vs 1.51; P = 0.001). Fewer complications (hematoma
or arterial puncture) occurred in the ultrasound
group compared with the anatomic landmark group (5.5%
vs 18.2%; P = 0.04).253
One observational study (n = 202) compared
fluoroscopy-guided CVC placement (n =136) to CVC
placement without imaging (using a slightly modified
traditional technique of introducer insertion without the
rigid dilator; n = 66).250
All CVCs were placed in the internal
jugular vein, with the majority (83%) placed on the
right side. There was a significantly higher success rate
(defined as placement and use of the CVC with adequate
blood flow) with fluoroscopy (98% vs 92%; P = 0.03).
Significantly more CVCs were placed on the right side in
the nonimaging group (91% vs 80%; P = 0.02). This study
reported bleeding events and showed no significant difference
between groups for major, minor, or total
bleeding events. Total bleeding rate was 1.5% in the
fluoroscopy-guided placement group and 3.0% in the
nonimaging placement group
Overall, KDOQI cannot suggest the use of image-guided
CVC insertion based solely on reducing complication rates,
because the complication rates are not significantly
different with ultrasound-guided versus traditional placement
techniques. Given the strength of the available evidence,
further high-quality studies on image-guided CVC
insertions and complication rates are needed.
Postinsertion imaging should be considered to avoid
malpositioning of CVCs.254,255
Proper location of the CVC
tip is at the mid right atrium to avoid vessel and right atrial
trauma and consequent complications. Malpositioning can
lead to vascular perforation, venous thrombosis, catheter
malfunction, and cerebral migration. Such complications
have been documented to occur in 1% of CVCs placed into
the right internal jugular vein via ultrasound guidance in a
retrospective single-center study, where 75% of CVCs were
placed by trainees (residents/fellows).254,255
In a prospective
study, 1.4% of right internal jugular vein CVCs
were malpositioned when placed by an anesthesiologist
with the aid of anatomic landmarks without image
guidance.255
Factors associated with tunneled CVC tip malpositioning
include change in position from supine to upright
position, which may be accentuated in obese patients and
female patients.256
Consistent with the 2006 KDOQI
guideline, it is reasonable to consider imaging for correct
CVC location when catheter dysfunction persists that is
unresponsive to conservative maneuvers and TPA
administration.13
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S54-S59.
Guideline 9. CVC Insertion
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S65
Special Discussions
The preferential order of CVC insertion (eg, right internal
jugular vein, left internal jugular vein, etc) is addressed in
a separate section (Guideline 3).
The proper location of the CVC tip is at the mid right
atrium (see Detailed Justification above).
Implementation Considerations
To ensure competency for procedural skills to insert
nontunneled (uncuffed) CVC, nephrology fellowship
programs have incorporated simulation-based learning.
The focus has shifted from tallying the number of procedures
performed to a more focused measurement of the
necessary components of the process for successful performance
of this procedure. Procedural training, which
includes placement of nontunneled HD CVC, is also a
requirement of the American Board of Internal Medicine
and the Accreditation Council of Graduate Medical
Education.257
Such training is highly desirable for all jurisdictions and
personnel—at any level of training or practice—who need
to insert CVCs for HD. Given the global nature of HD and
travel of HD patients, a minimum level of procedural
training for CVC insertion would provide standardization
of care.
Future Research
Additional clinical studies are needed to identify the ideal
means to insert a CVC for HD. Imaging appears to favorably
affect successful placement and may reduce complication
rates. Both ultrasound and fluoroscopy have been
studied thus far, with the former being most used for
placement of the CVC and the latter being used primarily
to ensure appropriate CVC tip localization.
Newer technologies include vein-localizing tools based
on near-infrared spectroscopy; near-infrared radiation is
absorbed by hemoglobin and reflected by neighboring
tissues, thereby outlining the vascular tree and allowing
visualization of the vessels through the overlying skin.258
This technology has been used to increase successful
placement of PICCs in neonates.259
Whether this technology
has application in adults for CVC placement, and
whether it warrants comparison to real-time ultrasonography
as an imaging technique to enhance CVC placement,
would be subjects for future studies.
Guideline 10. Post–AV Access Creation/CVC
Insertion Considerations
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statement: AV Access Early Postoperative
Considerations (0-30 days)—Early AV Access
Complications
10.1 KDOQI considers it reasonable for AV access
(AVF and AVG) to be evaluated by a surgeon/
operator for postoperative complications within
2 weeks and for an appropriate member of the
vascular access team to evaluate for AVF maturation
by 4-6 weeks after AV access creation and
refer for further investigation if not maturing as
expected. (Expert Opinion)
Note: Ideally, the surgeon/operator evaluating for complications
would be the same individual who created the AV access.
Rationale/Background
After creation of an AV access, there are 2 issues that need to
be addressed: early surgical complications and usability or
maturation of the AV access. Early surgical complications
need immediate attention and are best addressed by the
surgeon or operator who created the vascular access. A
knowledgeable member of the vascular access team (eg,
nephrologists and/or nurses skilled in AVF examination)
can determine usability and maturation. Typically, an AVG
can be used almost immediately (early stick AVG) or at 2
weeks (standard AVG) after creation. An AVF should be
evaluated for maturity at 4 to 6 weeks after creation; if
concerned, arrangements must be made for further investigations,
such as an ultrasound examination.
Detailed Justification
Surgeons typically see patients within 2 weeks after
construction of the vascular access to assess wound
healing and evaluate for potential complications. Early
complications of the vascular access are thrombosis,
immaturity, infection, pain, numbness, weakness, and
edema of the ipsilateral arm/hand.260,261
Infections are
more common after AVG than AVF placement. The majority
of AVG infections occur in the first month after
placement.262
Hand or finger tingling and numbness
can occur from soft tissue swelling and hematomas
compressing nerves but usually resolves within 4
weeks.261
Pain, numbness, weakness, and paralysis of
the hand and fingers with a warm hand, often occurring
immediately after surgery, suggests ischemic nerve
damage, a condition called ischemic monomelic neuropathy
that typically requires immediate ligation of the vascular
access.263
Hand and finger pain with a cold and blue
hand suggests ischemia that needs surgical measures to
reperfuse the hand264,265
(Guidelines 18 and 19). Limb
edema could result from the surgical procedure itself
but, if persistent (>2 weeks), suggests central vein
stenosis, especially if the patient currently has or had
ipsilateral CVC(s) or other central vein damage/
manipulation.266
Guideline 10. Post–AV Access Creation/CVC Insertion Considerations
S66 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
AVF examination for maturity is important especially if
patients are dialyzing with a CVC. The earlier AVF
immaturity is detected and addressed, the shorter the time
the patient receives HD with a CVC. An experienced and
knowledgeable member of the vascular access team, such
as dialysis nurses and nephrologists skilled in AVF examination,
can accurately assess maturity in most AVFs at 4
weeks after creation.4,127
In 1 study, experienced dialysis
nurses were able to predict with 80% accuracy the ability
to use AVFs for dialysis.127
The major causes of AVF failure
to mature can be detected by physical examination of the
AVF.267-269
The tools provided by the Fistula First Catheter
Last initiative have not been validated but can still be
helpful, such as the “AVF Quick Reference” guide.270,271
The arm-raising test assesses adequacy of venous
outflow, and the augmentation test assesses adequacy of
arterial inflow. In addition, the examination may reveal
a large accessory vein or collateral vein and stenosis
contributing to AVF immaturity. If the physical examination
is equivocal, an appropriate follow-up investigation,
such as ultrasound examination with Doppler,
should be performed. This will help evaluate for causative
abnormality and assess AVF maturation progress
via AVF diameter and blood flow (brachial artery and
AVF). Minimum ultrasound criteria have been established
for AVF maturity at 4 weeks using vessel diameter
and flow parameters (vessel diameter, 4-5 mm and
blood flow, 400-500 mL/min).127,189,268,272,273
Should
a correctable cause for AVF immaturity be found (eg,
culprit stenosis or collateral vessels), this should be
corrected in a timely manner to facilitate AV access
maturation.
Special Discussions
Tools provided by Fistula First Catheter Last initiative have
not been validated but were created by a group of multidisciplinary
experts in HD vascular access that the Work
Group believed might be helpful. See esrdncc.org/en/
fistula-first-catheter-last/ffcl-resources/ffcl-professionals/
tools-and-resources/.
Implementation Considerations
Routine re-training of relevant health team members (eg,
annual basis) on postcreation/postinsertion evaluation and
monitoring for complications of AV access and CVC,
respectively, should occur to maintain and update
knowledge for optimal vascular access care.
Monitoring and Evaluation
Evaluate whether the 2 to 4–week timelines suggested
need to be altered according to each facility’s logistics and
practice patterns and what impact it has on a patient’s AV
access complications and usability.
Future Research
Validate tools provided by Fistula First Catheter Last for
AVF maturation and the impact on AVF usability.
Statements: Postoperative AV Access Maturation
Patient Enhanced
10.2 There is inadequate evidence for KDOQI to make
a recommendation on the use of upper extremity
exercise to facilitate postoperative AVF
maturation.
10.3 KDOQI recommends the use of whole arm rather
than finger exercise, if exercise is used to facilitate
AVF maturation. (Conditional Recommendation,
Moderate-High Quality of Evidence)
Pharmacologic Intervention
10.4 KDOQI does not suggest the use of heparin as an
adjuvant therapy in the perioperative period to
improve primary patency or initial use of AV
access (AVF or AVG). (Conditional Recommendation,
Low Quality of Evidence)
10.5 KDOQI does not suggest the use of adjuvant
clopidogrel monotherapy initiation in the perioperative
period to improve AVF maturation and
reduce the likelihood of primary failure. (Conditional
Recommendation, Low Quality of Evidence)
10.6 KDOQI does not suggest the use of glyceryltrinitrate
to enhance AVF maturation. (Conditional
Recommendation, Low Quality of Evidence)
10.7 KDOQI does not suggest the use of cholecalciferol
to enhance AVF maturation. (Conditional Recommendation,
Moderate Quality of Evidence)
10.8 There is inadequate evidence for KDOQI to make
a recommendation on the use of clopidogrelprostacyclin(iloprost)
for AVFusability or patency.
Endovascular and Surgical Intervention
10.9 There is inadequate evidence for KDOQI to make a
recommendation on the preferred use of surgical
or endovascular techniques for postoperative
maturation. It is reasonable to consider a careful
individualized approach to using either surgical
techniques or endovascular techniques when
needing to intervene on an AV access to enhance
maturation postoperatively.
Guideline 10. Post–AV Access Creation/CVC Insertion Considerations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S67
Rationale/Background
AVF maturation failure and AVG thrombosis remain major
clinical problems for HD patients. Unfortunately, 20% to
60% of AVFs created fail to mature successfully for dialysis
use.77,233,234
Thrombosis accounts for almost 80% of AVG
failures235,236
due to an underlying stenosis at the venous
anastomosis.237-239
At present there are few, if any,
effective therapies to enhance AVF maturation and reduce
AVG stenosis and thrombosis. Patient-enhanced and
pharmacologic therapies to assist postoperative AV access
maturation and stenosis/thrombosis prevention were not
addressed in the 2006 KDOQI guideline.13
Moreover, the
type of intervention (eg, surgical or endovascular) was not
addressed in the 2006 KDOQI guideline. Since the 2006
KDOQI guideline, there have been several RCTs evaluating
therapies to assist AVF maturation and prevent AVG
thrombosis in the early postoperative period.
Detailed Justification
Patient-Enhanced Postoperative Maturation
Among the postoperative interventions to promote AVF
maturation that were reviewed, 1 patient-enhanced postoperative
procedure and 1 pharmacologic therapy demonstrated
significant benefit to improve postoperative
maturation. Although commonly practiced, there is inadequate
evidence demonstrating the benefit of arm exercises
for AVF maturation. Arm exercises after AVF creation should
be positively considered, despite some literature suggesting
no benefit versus control, in part because it is noninvasive,
has little to no harm, and requires minimal costs.
Directed Upper Extremity (Elbow/Wrist/Hand)
Postoperative Exercise Program Versus Routine
Postoperative Care
Fontsere et al274
(N = 72) compared isometric exercises
along the whole arm postoperatively to usual routine
postoperative care, allocating 39 patients to the exercise
and 33 patients to the control group. The exercise intervention
included repetitive exercise of the elbow, wrist,
and hand using a flex band, for a duration of 1 month after
AVF creation. The control group was not asked to perform
specific exercises. Potentially relevant drug use (eg, anticoagulant)
was similar among treatment groups. Clinical
AVF maturation, defined as an easily palpable vein by
physical examination, with a straight-superficial segment,
length of more than 10 cm, sufficient diameter, and good
palpable thrill, at 1 month was not statistically different
between the exercise group (95%) versus the control
group (81%) (RR, 1.18; 95% CI, 0.97-1.42).274
This
nonsignificant result was consistent with that found by
using ultrasound criteria for AVF maturation, defined as a
draining vein diameter of ≥5 mm, skin-vein distance
of ≤6 mm, and brachial blood flow rate of ≥500 mL/min
of the exercise (82%) and control groups (74%), respectively
(RR, 1.10; 95% CI, 0.85-1.42).7
There was no difference
between the exercise and controls groups for (1)
change in mean brachial artery flow (+389 mL/min [exercise]
vs +431 mL/min [control]; P = 0.99); (2) change
in mean venous diameter (+2.1 mm [exercise] vs +2.5
mm [control]; P = 0.30).7
Harms, including potential
repetitive stress injury, were not assessed. AVF location as
an effect modifier was analyzed. Proximal AVF (brachialcephalic,
brachial-basilic) was 50% (19/38) in the exercise
group and 68% (21/31) in the control group, with no
difference in clinical maturation. Clinical maturation of
distal AVF was achieved by 95% in the exercise group and
60% in the control group. However, the effect of location
(proximal vs distal AVF) on clinical maturation was not
significant (odds ratio [OR], 3.78; 95% CI, 0.74-19.16).
The effect of location on maturation became statistically
significant when ultrasound measures were used (OR,
6.82; 95% CI, 1.76-26.40). AVF maturation defined by
ultrasound criteria for proximal AVF was achieved by 95%
in the exercise group and 86% in the control group and in
distal AVF was achieved by 69% in the exercise group
versus 50% in the control group. Clinical usability was not
assessed in this study.
Arm Exercise Versus Finger Exercise
In a single-center study, Salimi et al275
compared isometric
exercises of the whole arm (n = 25) to limited finger
movements (n = 25). The intervention group performed
exercises at home, using a tourniquet placed 15 cm above
the AVF incision site. It included a defined number of exercise
repetitions over specific time frames: 4 times a day
for 2 weeks after AVF creation that involved the hand,
lower arm, elbow, and upper arm. Exercise difficulty
progressed over the study period by making the exercises
more challenging and adding in the use of light dumbbells
(0.5 kg) and flex bands. The comparison group did not
have a specified routine but were asked to routinely open
and close their fingers.275
Originally, 55 patients (n = 25 in
control group and n = 30 in intervention group) were
recruited, but 5 participants in the intervention group who
did not comply were not analyzed and not reported.
Clinical maturation, defined as a palpable, relatively straight
with >10 cm length of the superficial vein and a uniform
thrill on palpation, at 2 weeks improved with arm exercises
(52%) versus finger exercise (20%) (RR, 2.60; 95% CI,
1.09-6.20). Maturation by ultrasound criteria, defined as
draining vein diameter of ≥6 mm, skin-vein distance of ≤6
mm, and blood flow rate of ≥600 mL/min, were considered
because AVF ultrasonographic maturation criteria at 2
weeks were not statistically different between the whole
arm (88%) and finger (68%) exercise groups (RR, 1.29;
95% CI 0.9501.76). The change in flow rate at 2 weeks was
Guideline 10. Post–AV Access Creation/CVC Insertion Considerations
S68 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
not statistically different with arm exercise (+431 mL/min)
versus finger exercise (+316 mL/min) (mean difference,
114 mL/min; 95% CI, -41.0 to 269). There was no difference
between groups for (1) mean change in the
draining vein diameter: -2.32 mm (whole arm exercise)
versus +1.63 mm (finger exercise) (mean difference, +0.72
mL/min; 95% CI, -0.20 to +1.64) or (2) mean change in
the skin to vein distance: -1.95 mm (whole arm exercise)
versus 1.80 mm (finger exercise) (mean difference, -0.15;
95% CI, -1.01 to 0.71).275
Pharmaceutical Treatment Postoperative
Maturation
Heparin in AVF and AVG. Four trials with a total of 336
participants276-279
evaluated heparin for AV access maturation;
the statistics provided here are for this combined
cohort. D’Ayala et al,278
Bhomi et al,276
and Wang et al279
were eligible to be pooled together and resulted in a study
population with mean age of 52, and 54% male. Primary
patency was reported in 3 trials276,278,279
: short-term
primary patency (<60 days) was not different with heparin
or no adjunctive treatment (RR, 1.01; 95% CI, 0.64-
1.60). The ability to use the AVF for dialysis at 3 months
did not differ between participants who received heparin
versus no adjunctive treatment (RR 1.13; 95% CI, 0.82-
1.57). Harms reporting was inconsistent across studies.
Two trials reported hematomas.276,279
Bhomi et al had no
hematomas in either group, whereas there was no statistical
difference in hematomas with heparin (12%) versus
no heparin (5%) in Wang et al (RR, 2.68; 95% CI, 0.30-
24.1). AVF thrombosis was reported by Chen et al277
and
occurred in 13% of the heparin-treated group and 17% in
the no-heparin group (RR, 0.80; 95% CI, 0.34-1.89).
None of the trials assessed the effect modification of patient,
vessel, or care delivery characteristics.
Clopidogrel. Two trials with low risk of bias enrolled a
total of 970 participants.280
Dember et al31
randomized
877 patients to clopidogrel 300 mg the first day after AVF
creation, followed by clopidogrel 75 mg daily or placebo
treatment for 6 weeks and were followed up until 150 to
180 days after AVF creation or 30 days after initiation of
dialysis, whichever occurred later. Ghorbani et al280
randomized
93 patients in a separate study, 46 to clopidogrel
75 mg daily versus 47 to placebo control daily, 7 to 10
days before AVF creation up to 6 weeks postoperatively.
These 2 studies were eligible for pooling, which resulted
in a study population with mean age of 51 years and 58%
male. (Primary failure, defined as thrombosis 6 weeks after
AVF creation, favored the treatment group at 6 weeks in
Dember et al: RR, 0.63; 95% CI, 0.46- 0.86.31
) At 8
weeks, the primary failure outcome in Ghorbani et al
showed no statistical difference between treatment arms
(RR, 0.26; 95% CI, 0.06-1.14). The pooled failure rate
that was not statistically different with clopidogrel (11%)
versus placebo (19%) (RR, 0.55; 95% CI, 0.29-1.03). The
ability to use the AVF was not different with clopidogrel
(38%) versus placebo (41%) at 6 weeks (RR, 0.94; 95%
CI, 0.79-1.13) or at 6 months (clopidogrel [52%] vs
placebo [51%]; RR, 1.02; 95% CI, 0.69-1.51). Serious
harms, bleeding, and thrombosis were reported by 1 or
both studies31,280
and were not statistically different with
clopidogrel versus placebo. Dember et al reported no
statistical difference in surgical or percutaneous interventions
with clopidogrel (1.6%) versus placebo (2.3%)
(RR, 0.69; 95% CI, 0.27-1.81). No trial assessed the
effect modification of patient, vessel, or care delivery
characteristics.
Glyceryl-Trinitrate. Field et al’s single-center trial281
randomized 99 to the glyceryl-trinitrate group and 101
to the placebo group. Of these, 167 patients completed
surgery, 86 received glyceryl-trinitrate transdermal patch,
and 81 received a placebo patch applied near the anastomosis/incision
site and then dressed, immediately after
surgery. Patients were told to remove the patch after
24 hours and were followed for 6 weeks. Radiocephalic
or brachiocephalic AVF were included. Data from 167 of
the 200 randomized patients was used in the analysis.
Primary fistula failure at 6 weeks was not significantly
different with glyceryl-trinitrate patch (28%) versus placebo
(23%) (RR, 1.19; 95% CI, 0.71-2.0). Venous
diameter mean change showed no statistical difference
between the glyceryl-trinitrate patch (+2.2 mm) versus
placebo (+2.3 mm) (mean difference, -0.10; 95% CI,
-0.66-0.46).281
Cholecalciferol. Wasse et al282
randomized 52 prevalent
HD patients scheduled to have AVF creation within 4
weeks to oral vitamin D3 (cholecalciferol) 200,000 IU
weekly (n = 25) or placebo (n = 27) for 3 weeks and
followed them for 6 months. Eight participants died, were
lost to follow-up, or never received permanent access,
leaving 44 participants in the study. Nine (20%) of these
44 participants ended up receiving AVGs instead of AVFs.
The ability to use the AVF at 6 months was not statistically
different between cholecalciferol (45%) and placebo
(54%) (RR, 0.83; 95% CI, 0.45-1.53).
Clopidogrel and Iloprost. Abacilar et al283
randomized
96 participants to a combination of clopidogrel and iloprost
(n = 40) or placebo (n = 46) and followed them for
1 year. Those on treatment were given 75 mg/day of
clopidogrel and 200 mg/day iloprost (clopidogrel/iloprost)
starting 7 to 10 days before surgery and continuing
for 52 weeks. Primary failure was lower with clopidogrel/
iloprost (8%) over placebo (30.4%) at 4 weeks (RR, 0.26;
95% CI, 0.09-0.74). Primary patency was higher with
clopidogrel/iloprost (85%) versus placebo (68%) at 3
months (RR, 1.28: 95% CI, 1.02-1.61). Maturation was
better with clopidogrel/iloprost (87%) versus placebo
(67%) at 3 months (RR, 1.28; 95% CI, 1.01-1.61). There
was no statistical difference in rates of adverse events with
clopidogrel/iloprost (18%) versus placebo (13%) (RR,
1.38 95% CI, 0.52-3.58) or reoperations (0% in clopidogrel/iloprost
vs 4% in placebo; RR, 0.20; 95% CI, 0.01-
4.06).283
Guideline 10. Post–AV Access Creation/CVC Insertion Considerations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S69
Although clopidogrel/iloprost in 1 study showed significant
benefit to improve primary patency and matura-
tion,283
consideration of use should be individualized in the
elderly and frail population. Detailed evaluation of the study
by Work Group members revealed study inconsistencies
that raised caution and led the group to lower its recommendation.
Indeed, the KDOQI Work Group discussed the
clopidogrel/iloprost study at length and believed that a
larger, rigorously designed and conducted RCT to evaluate
this drug regimen’s effect to improve AV access outcomes
would be needed. Furthermore, a much larger RCT with
more than 900 patients31
evaluating clopidogrel only versus
placebo did not demonstrate significant benefit to improve
clinical AVF use but did demonstrate significant benefit to
reduce early thrombosis. Thus, the true benefit of clopidogrel
to improve AVF maturation needs further evaluation.
Other Interventions
Data extraction on the type of intervention, endovascular
versus surgery, used to intervene on a nonmaturing AV
access was not performed. Formal comparative studies
directly evaluating these 2 methods in salvaging nonmaturing
AVFs are lacking. The studies published to date,
primarily regarding AVFs, have shown conflicting re-
sults.284-288
RCTs will be needed to determine the
appropriate type of intervention used to intervene for a
nonmaturing AVF. Moreover, recently, a more aggressive
approach to AVF maturation failure in which repeated
long-segment angioplasty procedures (BAM) has been
used to sequentially dilate up the peri-anastomotic venous
segments. Two single-center studies evaluating BAM
techniques to salvage nonmaturing AVFs have been published.
These 2 studies demonstrated that a large proportion
of immature AVFs could be salvaged for successful use
on dialysis, but postintervention primary unassisted
patency rates were poor, and the number of postmaturation
angioplasties per year to maintain function was
high.289,290
Prospective and randomized studies of BAM
compared with standard of care need to be performed in
the future.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S60-S89.
Special Discussions
Additional Work Group discussion determined that there is
a need to (1) provide a uniform recommendation on when
to abandon an AV access; (2) determine the best methods
to evaluate for postoperative maturation, including physical
examination techniques and imaging; (3) provide
uniform definitions of AV access maturation and patency
that are relevant for both clinical and study purposes; and
(4) create consensus guidelines to determine the best
protocols to intervene for nonmaturing AVF (eg, < and >6
weeks) and early AVG problems.
Implementation Considerations
Although some of these studies did not meet the prespecified
primary outcome, several important secondary
outcomes were achieved; thus, use of these therapies must
be considered on an individual basis. Moreover, therapies
such as clopidogrel, which is an antiplatelet agent, require
special consideration for use in the elderly and/or frail
population, who have a high risk of falls or other bleeding
events.
Future Research
The Work Group determined several areas for critical
future research in this area, which include (1) the role of
surgical versus endovascular procedures to enhance AVF
maturation; (2) the potential role of protocol-driven AVF
maturation (eg, BAM), in particular, the short- and longterm
risks and benefits of this procedure; (3) the potential
role of external assistance, such as the Fistula Assist
device in AVF maturation and others, that may be in
development or early-phase clinical studies and may be
promising.
Statements: Timing of CVC Removal
Noncuffed, Nontunneled Catheters (NT-CVC)
10.10 KDOQI considers it reasonable to limit the use
of temporary, noncuffed, nontunneled dialysis
catheters to a maximum of 2 weeks due to
increased risk of infection, and this should be
considered only in patients in need of emergent
access. (Expert Opinion)
Cuffed, Tunneled CVC
10.11 KDOQI considers it reasonable that in HD patients
for whom a cuffed, tunneled CVC is the
most appropriate permanent dialysis access,
there is no maximum time limit to CVC use, but
regular evaluation is required to determine if
the CVC remains the most appropriate dialysis
access. (Expert Opinion)
Note: Appropriate uses of a cuffed, tunneled CVC for chronic hemodialysis
include the following:
1) All other AV access options have been exhausted (after
thorough multidisciplinary evaluation)
2) Temporary switch from another modality (eg, PD, due to
PD-related complications such as pleural leak,
transplant–acute rejection, etc), but the patient is expected
to return to that modality after the complication is
adequately resolved
3) Awaiting live-donor kidney transplant with established
surgical date (<90 days)
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S70 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
4) Very limited life expectancy (eg, <6-12 months)
5) Clinical conditions that would worsen with AV access (eg,
HF with EF<15%, nontreatable skin lesions where cannulation/scratching
significantly increases infection or
rupture risk, etc)
6) Patient choice after proper informed consent (eg, competent,
>85-year-old elderly woman with high risk of AV access
failure, needle phobia, and unknown life expectancy)
Note: The above points regarding appropriate use of CVC are discussed
in Guideline Statement 2.2.
Rationale/Background
In patients for whom an AV access has not been created, is
not ready for use, or is not possible, HD can be performed
with a HD catheter. In the United States, 80% of patients
were using a CVC at HD initiation in 2015, which has
changed little since 2005.139
At 90 days after initiation of
dialysis, 68.5% of HD patients were still using a CVC.139
The type and duration of CVC use during this time must
be considered because it may have implications for patient
well-being.
Nontunneled, noncuffed catheters (NT-CVCs) serve a
temporary role for acute clinical situations where immediate
HD is needed and/or there are immediate barriers or contraindications
to placement of a cuffed tunneled catheter
(CVC). Sepsis, lack of image guidance, and uncorrectable
coagulopathy are examples of such barriers. It is known that
cuffed, tunneled CVCs have a lower risk of infection than
NT-CVC.291,292
Therefore, NT-CVC use should be limited.
A related question of when to switch from a NT-CVC to a
tunneled CVC in patients who do not recover from AKI has
not been addressed by prospective studies. However, 1
study noted that the need for dialysis in acute kidney injury
(AKI) often exceeded 3 weeks.293
The prior 2006 KDOQI guideline Statement 2.4 recommended
that there should be a plan to (1) discontinue
or (2) convert any short-term catheter (NT-CVC) to a
long-term catheter (CVC) within 1 week. As for maximum
CVC dwell time, there may be concerns about CVC durability
and of the CVC becoming incorporated or scarred
into the venous wall over a prolonged period of time.
Complications related to these concerns have been reported,
such as breakage and migration of CVC parts,
incorporated and retained CVC sections that have caused
fatal sepsis, etc.294
Although resistant adherent CVCs, also
known as stuck catheters, can be removed by endovascular
techniques, if unsuccessful, it may require open heart
surgery to extract scarred in CVCs.295
Despite these reports,
no studies have ascertained an ideal dwell time.
Furthermore, other opinion-based guidelines296,297
now
recommend against routine change of CVCs, including the
prior 2006 KDOQI guideline. Furthermore, there are
newly described techniques that allow minimally invasive
removal of stuck catheters298,299
in situations where the
cuffed, tunneled CVC is a valid choice for vascular access
but needs removal or exchange.
Detailed Justification
In terms of short-term use, in 1 study, the infection rate
increased exponentially after 1 week with actuarial analysis
of 272 catheters (37 CVC vs 235 NT-CVC) showing a
difference in infection rates by 2 weeks.291
Also, infection
rates per 1,000 days at risk for NT-CVC were more than 5
times greater versus internal jugular CVC and almost 7
times greater with femoral NT-CVC.291
In HD catheters for AKI or urgent/emergent HD
starts, a prospective multicenter RCT comparing
NT-CVC to CVC (internal jugular vein location) in
critically ill patients found a significant reduction in
CVC-related sepsis with CVC.300
A single-center retrospective
study found that mean CVC dwell time in
patients who eventually recovered from AKI was 34
days, with only 15 of 76 (20%) patients recovering
kidney function within 1 week.293
In terms of long-term use of HD catheters, although
there are concerns regarding stuck HD CVC with possible
embolization of fragments during removal attempts, there
have been recent techniques that now allow for extraction
percutaneously. These include laser extraction similar to
pacemaker lead extraction and intraluminal CVC dilation
that dislodges the CVC from vessel walls.298,299
Special Discussion
Although uncommon, complications such as resistant
adherent CVCs, also known as a stuck catheters, may require
management by operators with prior specialized experience.
Monitoring and Evaluation
Regular re-evaluation of the patient’s use of CVC required,
including whether the patient should receive conservative
care.
Future Research
 Testing long-term durability of dialysis catheters
 Materials to prevent resistant adherent CVCs (stuck
catheters); do newer removal techniques prevent stuck
catheters in the long term?
Guideline 11. Vascular Access Use
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S71
Statement: Vascular Access General Monitoring
11.1 KDOQI considers it reasonable to assess or check
the vascular access and surrounding area by
physical exam prior to every cannulation (if AV
access) or connection (if CVC) for potential
complications. (Expert Opinion)
Statements: AV Access Cannulation
Please review Guideline Statement 11.1.
11.2 KDOQI recommends rope ladder cannulation as
the preferred cannulation technique for AVFs.
(Conditional Recommendation, Moderate Quality of
Evidence)
11.3 KDOQI considers it reasonable to limit AV access
buttonhole cannulation only to special circumstances
given the associated increased risks of
infection and related adverse consequences.
(Expert Opinion)
11.4 KDOQI considers it reasonable to avoid buttonhole
cannulation in synthetic PTFE grafts due to
potential serious consequences. (Expert Opinion)
11.5 KDOQI suggests that when select buttonhole
cannulation is performed, the use of buttonhole
cannulation devices to facilitate cannulation
should be at the discretion and expertise of the
cannulator. (Conditional Recommendation, Low Quality
of Evidence)
11.6 KDOQI considers it reasonable to use skilled
cannulators with established high rates of cannulation
success to perform initial AV access
cannulations on patients to help avoid primary
infiltration injury of the AV access. (Expert
Opinion)
11.7 KDOQI considers it reasonable to have structured
training and supervision of dialysis technicians
and nurses before and during their initial cannulation
attempts, and regular training updates
to maintain cannulation competency. (Expert
Opinion)
11.8 KDOQI considers it reasonable to support and
educate eligible patients on self-cannulation of their
AV access (AVF or AVG). (Expert Opinion)
Note: To be clear, any consideration of buttonhole cannulation refers
only to AVF and certain AVG materials. AVG made of PTFE
should not be accessed by buttonhole cannulation, due to risks of
“one-siteitis” and its serious consequences.
Note: See Guideline Statement 12.2 for use of ultrasound for AV
access cannulation.
Rationale/Background
Once an AV access is created and nurtured to “readiness for
cannulation,” the next important step is AV access cannulation.
The first cannulation is often a source of anxiety
for the patient—and often for the cannulator as well.
Problems with cannulation can lead to a range of complications,
from mild infiltration injury to major hematomas
or blood loss requiring blood transfusions, and even
loss of the AV access. Mild infiltration injury can occur as
frequently as >50% of all AVF and major infiltrations of 5%
to 7%.3
Thus, it is critical to ensure that cannulators have
received adequate training and mentoring to facilitate and
achieve successful cannulation. A successful cannulation is
one where 2 needles of adequate size are inserted into the
AV access at the right depth and angle to facilitate prescribed
dialysis and in which this is achieved with minimal
pain or no complications. Different cannulation techniques
can be applied effectively301
but require skilled cannulators
who have received adequate initial and ongoing
training302
and continued close monitoring of the AV
access.
Detailed Justification
Technique
There were 5 unique RCTs and 7 observational studies
reviewed on cannulation technique. Three trials (total N =
265)303-305
compared buttonhole cannulation versus
rope-ladder (RL) cannulation. Neither AVF survival nor
pain with cannulation was statistically different with
buttonhole versus RL cannulation. For example, MacRae
et al303,304
showed no difference in AVF survival (RR,
1.04; 95% CI, 0.81-1.34). Although pain was not
different between techniques, lower use of lidocaine
with buttonhole cannulation was reported.
Patient satisfaction was also not significantly
different with buttonhole versus RL.305
Chow et al305
reported the Kidney Disease Quality of Life scale,
which includes the Short Form (SF) Health Survey. The
SF-12 physical and mental composite scales were
described as showing no significant difference between
groups. (The SF-12 physical composite score had mean
of 35.80 [buttonhole] vs 33.88 [RL]; the SF-12 mental
composite score had a mean of 42.58 [buttonhole] vs
44.39 [RL].)
The need for surgical or endovascular intervention was
also not significantly different between buttonhole and
RL.304
At 1 year, MacRae et al304
found the rate of surgical
intervention with buttonhole (0.09 per patient-year at
risk) versus RL (0.11 per patient-year at risk) (RR, 0.79;
95% CI, 0.33-1.89) and the rate of endovascular intervention
with buttonhole (0.90 per patient-year at risk)
versus RL (0.72 per patient-year at risk) (RR, 1.28; 95%
CI, 0.78-2.10). No other intermediate outcomes were
reported.
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S72 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Hematomas were reported with varying results.303,305
MacRae et al303
found significantly fewer hematomas per
dialysis session with buttonhole (295 per 1,000 dialysis
sessions) versus RL (436 per 1,000 dialysis session) at 8
weeks (RR, 0.68; 95% CI, 0.58-0.79). In contrast, Chow
et al305
reported significantly more hematomas with
buttonhole (12%) versus RL (0%) at 26 weeks (RD, 0.12;
95% CI, 0.01-0.23). There was no difference with
thrombosis or exit site infections. For example, pooled
analysis of 3 trials showed that exit site infections with
buttonhole cannulation had RR of 4.41 (95% CI, 0.16-
123.5)304-306
(Fig 11.1).
Of importance was the risk of serious AV access–related
infections. Staphylococcus aureus bacteremia was significantly
more frequent with buttonhole (13%) versus RL (0%) at 1
year (RR, 19; 95% CI, 8-46; RD, 0.13; 95% CI, 0.05-
0.21).304
The quality of evidence for this harm was strong
compared with the quality of evidence for other findings
of the cannulation technique.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement, 3 Tables S90-S97.
Aids to the Buttonhole Cannulation Technique
Two trials examined cannulation aids (total n = 226) and
assessed outcomes at 1 year. Vascular access failures were
significantly lower with buttonhole-peg cannulation (0%)
versus usual care (different-site) (13%) in 1 trial (RR,
0.06; 95% CI, 0.03-0.15; RD, -0.13; 95% CI, -0.21 to
-0.05).307
Total interventions (fistuloplasty or thrombectomy)
were significantly lower with buttonhole-peg cannulation
(19%) versus usual care (39%) in 1 trial (RR,
0.48; 95% CI, 0.26-0.89).307
Vaux et al307
reported that enlargement of existing
aneurysm was significantly lower with buttonhole-peg
cannulation (23%) versus different-site technique (67%)
(RR, 0.34; 95% CI, 0.12-0.99). However, development of
a new aneurysm did not differ: buttonhole-peg cannulation
was 4% versus different-site technique at 17% (RR,
0.27; 95% CI, 0.06-1.17).307
Of note, using a buttonhole cannulation aid was associated
with increased risk of cannulation site infection
(whereas not using one was not, as discussed). Exit-site
infections were significantly higher with buttonhole-peg
cannulation (3%) versus different-site technique (0%) in
a pooled analysis of data from the 2 trials (RR, 4.60; 95%
CI, 2.31-9.18).307,308
Again, the quality of this evidence
was stronger than the other outcomes.
Special Discussions
Given the high risk of infectious harms with buttonhole
cannulation (eg, S aureus bacteremia) and low evidence of
clinical benefit with buttonhole (eg, no difference in AV
access survival, surgical, and endovascular interventions or
patient comfort), the Work Group agreed on a cautious
approach to accessing the patient’s lifeline with a decision
to prefer the RL cannulation technique. However, they
recognized that circumstances do exist where buttonhole
cannulation may be necessary (Table 11.1). The Work
Group commented that, for in-home HD patients who
cannot cannulate using the RL technique, the infection risk
associated with buttonhole cannulation is similar to a
well–cared-for CVC309-313
; thus, the decision to continue
with an AVF with buttonhole cannulation or insert CVC
must be carefully considered, weighing the risks and
benefits or both in the context of the patient’s ESKD LifePlan.
The potential risks of “one-siteitis” and its consequences
in synthetic grafts made of materials such as PTFE
can be serious; therefore, the Work Group took a cautious
approach to avoid buttonhole cannulation in these circumstances.
The use of buttonhole cannulation in other
nonautogenous graft materials, such as bovine or other
biological material, is limited,314
so the Work Group
cannot comment on this. In the absence of evidence, the
Work Group considers it reasonable to use the same precautions
as with native AVF cannulation until data are
available.
In such situations where buttonhole cannulation is
appropriate, careful establishment of the buttonhole with
proper training, retraining, and close monitoring is
Figure 11.1. Buttonhole infection.
Table 11.1. Circumstances Where Buttonhole Cannulation May Be
Acceptable
AVF has only a short or small segment for cannulation
Enlarging or large aneurysm to prevent its further expansion
Failure of rope-ladder cannulation for cannulators (eg, home
hemodialysis) who have established excellent hygiene and cannulation
technique
Guideline 11. Vascular Access Use
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S73
required. Although the buttonhole-peg has potential advantages,
it is also associated with increased risks of cannulation
site infection, whereas buttonhole without aids
does not appear to share that risk (but has a high risk of
bacteremia). Thus, the decision to use a buttonhole aid
must be carefully considered in an individualized manner,
considering the characteristics and skills of both the patient
and cannulator, respectively.
The skill and experience of a cannulator is intuitively
important for cannulation outcomes, although there are no
rigorous studies reporting on this. The use of expert cannulators
to perform initial AVF cannulations was discussed;
however, there are no widely accepted or standardized
definitions of expert cannulator. Ideally, all nurses, technicians,
patients, and physicians cannulating an AV access
should have a level of proficiency such that both new and
established AV accesses can be cannulated with the same
degree of comfort, reliability, and success.
The specific details on the mechanics of accessing the AV
access, for example, clean or aseptic technique, were not
discussed but should follow universal infection control
guidelines and adhere to specific dialysis unit/institutional
policies. The use of graduated needle sizes, advancing blood
flow rates, and so on should be individualized to meet the
prescribed dialysis needs to achieve patient goals. Here,
consideration of the ESKD Life-Plan is very important. For
example, a patient on home nocturnal dialysis may be selfcannulating
with needles and blood pump speeds that are
quite different (eg, Qb of <300 mL/min) than a patient
being cannulated by a technician with 14-gauge needles to
satisfy a Qb of 450 mL/min in a 3- to 4-hour facility
dialysis session (as may be the case in some US facilities).
Furthermore, since the last Guidelines, the prior “Rule
of 6s” has been assessed by the National Institutes of
Health Hemodialysis Fistula Maturation Study. Although
blood flow, vein diameter, and depth were shown to be
important, when using criteria of fistula blood flow of 600
mL/min, vein diameter of 6 mm, and depth of 2 mm
below the skin, the likelihood of maturation success was
approximately 50%, with greater depths having poorer
maturation outcomes (in other words, a depth of 6 mm
would likely be less successful, if maturation was only 50%
with a depth of 2 mm).315
Thus, the cannulation criteria
needs to be revisited and studied further. The principals of
having a vein of adequate length and diameter that is easily
accessible (ie, not too deep and properly located to allow
for comfortable needle cannulation) continue to hold.
Cannulation criteria may, in part, be dependent on needle
size and blood pump speed needed to achieve adequate
dialysis. This is supported by the observed variation in
cannulation times and successes around the world in
studies comparing cannulation practices patterns.85,316,317
Finally, the use of ultrasound-guided cannulation was
discussed at length among Work Group members. Due to
the reliance on operator expertise, resources required,
mixed patient and user feedback, and the paucity of
literature to support its widespread use, the Work Group
supports its use in select patients until further research is
available. Select patients where ultrasound guidance may
be useful include first or new AVF cannulation where a
cannulator experienced and competent with ultrasound-guided cannulation
deems that it may aid in cannulation, in an AVF with
prior infiltration injury, or to avoid cannulation complications
(Guideline Statement 12.2).
Implementation Considerations
Training and retraining of cannulators is critical to ensure
maintenance of competency of cannulation skills. The use
of cannulation simulation may be beneficial and should be
studied.
Monitoring and Evaluation
New or altered cannulation protocols should be monitored
in a continuous quality improvement manner to establish
that change has made an improvement (eg, a reduction in
the rate of infiltration injury).
Future Research
 Study of criteria for AV access readiness to cannulate
 Rigorous study of use of ultrasound-guided cannulation—its
safety, efficacy, and impact in busy dialysis
units—is needed
 More study of the details of the mechanics of cannulation
at a patient level (eg, needle size and type, angle,
retrograde/antegrade, graduated flow rates under
varying circumstances) for best patient and dialysis
outcomes is required
 Evaluating different simulation models and techniques
for improving cannulation success—does it improve
cannulation competency, reduce cannulation complications,
and improve patient satisfaction?
 Define expert cannulator and how such expert cannulators
can maintain their expertise and be best maximized to
improve overall cannulation success within a dialysis
unit or for the individual patient
 Rigorous studies to evaluate the use and outcomes
associated with alternative cannulation-assistive devices
 The safety, efficacy, and patient satisfaction with using
plastic cannulae
 Safety of buttonhole cannulation in nonautogenous,
biologic graft materials
Statements: CVC System Connect and Disconnect
Procedure Considerations
Please review Guideline Statement 11.1.
11.9 KDOQI suggests the use of a catheter care protocol
for exit site and hub care to reduce catheterrelated
bloodstream infections and treatment of
catheter dysfunction. (Strong Recommendation, Moderate
Quality of Evidence)
11.10 KDOQI considers it reasonable, in addition to
correct hand hygiene/washing, to use aseptic
Guideline 11. Vascular Access Use
S74 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
technique and masks for patients and staff performing
catheter connection and disconnection
procedures. (Expert Opinion)
11.11 KDOQI considers it reasonable to cleanse the
catheter hub when connecting and disconnecting
the catheter with a chlorhexidine based
solution. If chlorhexidine is contraindicated
(eg, sensitivity, allergy), povidone-iodine solution
(preferably with alcohol) is a reasonable
substitute and should be used. (Expert Opinion)
11.12 KDOQI considers it reasonable at the time of
catheter dressing change to cleanse the skin
surrounding the catheter exit site with a
chlorhexidine based solution. If chlorhexidine
is contraindicated (eg, sensitivity, allergy),
povidone-iodine solution (preferably with
alcohol) is a reasonable substitute and should be
used. (Expert Opinion)
11.13 There is inadequate evidence for KDOQI to
make a recommendation on the specific chlorhexidine
formulation to use for infection prophylaxis,
and this should be based on the
clinician’s best clinical judgment and local
practical considerations.
11.14 There is inadequate evidence to demonstrate a
difference in catheter-related infections with the
use of transparent film dressing compared with
nontransparent dressing; thus, the choice of
catheter dressing material should be based on the
clinician’s discretion that considers the patient’s
circumstances and uses best clinical judgment.
11.15 KDOQI considers it reasonable to use a topical
antiseptic or antibiotic barrier at the catheter
exit site in addition to cleansing until the exit
site is healed to reduce the risk of catheterrelated
infection. (Expert Opinion)
11.16 There is inadequate evidence to demonstrate a
difference in catheter-related infections
between the use of various antiseptic or antibiotic
topical exit site barriers; thus, the choice
of topical exit site barrier should be based on
the clinician’s discretion and best clinical
judgment.
11.17 KDOQI considers it reasonable to follow these
catheter care practices (Expert Opinion):
 The frequency of catheter dressing change
should be based on the clinician’s discretion
and best clinical judgment, with a minimum
of once weekly
 Catheter dressings should be protected against
wet and dirty environments, particularly when
the exit site is not yet fully healed (eg, avoid
swimming and showering)
Note: See Guideline Statements 21.2 and 21.3 for statements on
CVC connectors to prevent CVC dysfunction or bacteremia and
Guideline Statements 24.3-24.5 for statements on intraluminal
strategies for the prophylaxis of CVC-related infections.
Rationale/Background
Hemodialysis CVCs, when compared with AV access, are
associated with a 2- to 3-fold higher risk of infectionrelated
hospitalization and associated costs due to
catheter-related blood stream infections (CRBSI).67,318,319
Contamination of the external and internal CVC surface
through both the extraluminal and intraluminal pathways,
respectively, involves the transfer of organisms during CVC
manipulation, such as during dressing changes or
connection and disconnection of the CVC. The transfer of
organisms are from either the health providers’ or patients’
hands (if patient does own CVC care), the patient’s skin, or
surrounding clothing to the CVC exit site opening and
tunnel (extraluminal pathway of organism entry) or to the
external or internal surfaces of CVC hubs or caps (extraluminal
or intraluminal pathway)297,320
(Fig 11.2). As
such, some guidelines have recommended (1) minimal
manipulation of the CVC to reduce the risk of infection,
(2) limiting access of HD vascular access to personnel who
are adequately trained, and (3) need for regular re-training
Figure 11.2. The pathogenesis of biofilm formation. Abbreviation: EPS, extracellular polymeric substance. Reproduced from Lok665
with permission
of Elsevier; original image © 2006 by the National Kidney Foundation, Inc.
Guideline 11. Vascular Access Use
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S75
of individuals handling HD catheters (or any dialysis ac-
cess).321
As a result, many dialysis units restrict accessing
the CVC to the provision of HD, unless in emergency
situations. The prior 2006 KDOQI guideline recommended
CVC dressing changes at each dialysis session.320
The current guideline differs by suggesting only the
necessary minimal manipulation of CVC until the exit site
and tunnel are healed to reduce the risk of infection. This
Guideline suggests the preferred use of chlorhexidine for
CVC and exit site cleansing, unless contraindicated, similar
to prior recommendations.
Detailed Justification
Vigilant CVC care is required, including regular inspection
of the CVC, tunnel, and exit site, and adherence to CVC
care protocols. Both the patient and the HD staff should
follow universal precautions and hygienic measures. The
2006 KDOQI guideline recommended that staff manipulating
CVCs should wear a mask and clean or sterile
disposable gloves; however, the data supporting masks are
extrapolated from studies of their use during CVC inser-
tion.322,323
During CVC insertion, the risk of infection is
high due to direct exposure of the vessel and bloodstream
to the external environment. Whether or not masks are
required is unclear in situations where the exit site is
healed. However, extra protection is theoretically afforded
if the health care provider or patient inadvertently sneezes,
coughs, or spits (eg, while talking) during CVC care. The
use of sterile gloves (vs new clean gloves) is also controversial,
particularly when the use of no-touch techniques is
strictly enforced.
Hub Care
Risks of contamination of the hub and infection include
(1) contact of the exposed CVC hub with a nonsterile
surface (eg, bedside desk) or object (eg, hand) (2) prolonged
exposure to the air (3) improper cleansing of the
hub, and (4) patient or provider breathing on the exposed
hub.324
Thus, it is important to reduce the hub exposure
time, and diligent hub cleansing is required. Doing so can
result in a marked (almost 4-fold) decrease in CRBSI
rates,325
approaching a rate of 1 episode/1,000 catheter
days.325
Thus, adopting protocols that incorporate limiting
hub exposure time and increasing protection by vigorously
“scrubbing the hub” is very important and is supported by
these and other guidelines.296,297
Catheter and Exit Site Cleansing
One cluster RCT (n = 422 facilities) compared a new CVC
care protocol involving exit site disinfection with 2%
chlorhexidine and 70% alcohol swab sticks and 70%
alcohol pads for hub care to current practice (no specific
disinfectant, no scrubbing of CVC hubs326
). Significantly
fewer blood stream infections were reported in the intervention
facilities. A patient-level analysis, adjusted for a
cluster effect, yielded an RR of 0.79 (95% CI, 0.78-0.81).
Adverse events were reported only for the intervention
facilities, which included chlorhexidine sensitivity. A total
of 184 local, non–life-threatening events were reported in
82 study participants.
In a pilot RCT (n = 105), a 2% chlorhexidine in 70%
isopropyl alcohol solution was compared with chlorhexidine
solutions (either 0.5% chlorhexidine in alcohol [81%
of control group] or 0.05% aqueous chlorhexidine [19% of
control group]) for CVC exit site antisepsis.327
Follow-up
was 12 months. Overall, fewer CVC-related infections
were noted in the intervention group compared with the
control group, but the difference was not significant (RR,
0.49; 95% CI, 0.18-1.34). There were also no significant
differences between groups for specific types of infection
(ie, CRBSI or exit site). Skin sensitivity reaction was reported
in 4 participants in the 2% chlorhexidine in 70% alcohol
group (Fisher exact test, P = 0.12)
Given this evidence, the Work Group strongly suggests
using a CVC care protocol that involves chlorhexidine and,
if circumstances permit, using chlorhexidine gluconate 1%
or 2% and 70% alcohol solution.296,297
Additional research
by the Work Group found chlorhexidine skin cleansing to
be superior to povidone-iodine and alcohol in the prevention
of CVC-related infection.328-330
If chlorhexidine is
contraindicated (eg, skin sensitivity or allergy), povidoneiodine
10% in 70% ethanol should be used.331
The antiseptic
solution should be applied using friction, for at least
30 seconds, and allowed to air-dry without wiping or
blotting, to promote adherence of the dressing material to
the skin and reduce the likelihood of skin breakdown and
infection. Multidose cleansing solution bottles are
discouraged due to the risk of cross-contamination. All
cleansing solutions should be single use, for example, a
disposable swab stick or pad.297
Exit Site Barriers and Dressings
The routine application of topical antiseptic/antibiotic
ointments at the CVC exit site has been shown to be
associated with a 75% to 93% reduction in the risk of
CRBSI.332-334
Topical ointments that have been studied
include mupirocin, povidone-iodine, and Polysporin tripleantibiotic
ointment. A 6-year prospective follow-up study
using a Polysporin triple-ointment application at the exit site
of HD catheters has not demonstrated microbial resistance
or loss of efficacy for infection prophylaxis, with bacteremia
rates consistently <1.0/1,000 catheter days.309
Medicalgrade
honey has been shown to have equivalent efficacy
to mupirocin for CRBSI.335
Such findings are supported by
the ERT. For example, bacteremia occurred in 12% with
medical-grade honey and 10% with mupirocin prophylactic
application at the CVC exit site (P = 0.78).336
Bacteremiafree
survival also did not differ between these groups
(HR, 0.94; 95% CI, 0.27-3.24).
Given the reduction in CRBSI using topical antiseptic or
antibiotic barriers compared with placebo or no barrier,
but no significant differences between types of antiseptic/
antibiotic barrier, the Work Group suggests the choice of
barrier based on the clinician’s best clinical judgment and
Guideline 11. Vascular Access Use
S76 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
local practices. Whether the benefit exists after exit sites are
fully healed is unclear. However, it is important to recall
that exit sites require re-healing after each CVC exchange.
As with the use of any intraluminal solutions, any
cleansing solution or antiseptic/antibiotic used topically
should be compatible with the CVC material.
All dressing material should be applied using notouch
or aseptic techniques. No-touch technique means that
all open ports and ends of CVCs are not touched with
hands or gloves (see http://antt.org/ANTT_Site/home.
html). Recent data indicate that there is no significant
difference between transparent, semipermeable dressings,
and standard gauze dressings with respect to CVC exit site
colonization or CRBSI.337-339
This is also supported by the
ERT. For example, 1 small RCT (n = 66) compared 2
dressings: a sterile transparent film and a traditional sterile
gauze and hypoallergenic micropore dressing.340
No significant
difference in CVC-related infection (12% intervention,
9% control; P = 0.69) was found.340
Both patient and environmental factors should be
considered when selecting dressing type and the frequency
of change (discussed earlier). Dressings should not be
submerged in water and should be changed when they
become damp, loose, soiled, nonocclusive, or nonadherent,
and only trained dialysis care providers
(including patients) should change CVC dressings. Regular
retraining is highly desirable to maintain competency and
reduce the risk of infection.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S98-S109.
Assessment of CVC Patency
Routine flushing with 0.9% normal saline is used to
maintain CVC patency and has become a standard of
practice when accessing and de-accessing CVCs.
Flushing of CVC lumens is intended to prevent the
mixing of incompatible medications or solutions
within the CVC lumen and assists in clearing the CVC
of blood) or fibrin buildup.341
Typically, a 5- to 10mL
syringe is used; given the lack of evidence for
syringe size, the CVC manufacturer’s instructions may
be used as a guide. However, the clinician is expected
to use his/her best clinical judgment and follow local
CVC care protocols.
Table 11.2. Example of CVC Connect and Disconnect Procedures
Suggested Method to Access CVC
Step 1: Explain the procedure to the patient. Ask him/her to minimize talking and turn the head the opposite direction of the CVC.
Step 2: Perform hand hygiene. Remove any gauze or tape securing the CVC or covering CVC limbs.
Step 3: Ensure that both limbs of the CVC are clamped. Place clean or sterile pad/towel under the CVC so that the limbs are on top of the pad/
towel.
Step 4: Perform hand hygiene and prepare supplies, maintaining sterility. Put on gloves.
Step 5: Ensure clamp on CVC is closed. Remove the Luer lock cap and clean the hub (“scrub the hub”)297
with chlorhexidine (or povidone if
chlorhexidine not tolerated). Ensure that the disinfected hub does not touch nonsterile surfaces. If closed system, high-flow, needleless-style
caps are used; follow the manufacturer’s recommendations and CVC care for cleaning and changing of caps. Repeat with the second port.
Optional for Step 5: Before removing the Luer lock cap, disinfect the caps and part of the hub with an antiseptic pad, using a separate
antiseptic pad for each hub or catheter limb.
Step 6a
: Attach syringe, unclamp CVC, and aspirate 2 to 5 mL of blood and CVC locking solution from lumen. Reclamp CVC. Detach syringe and
attach to dialysis circuit. Repeat with second port.
Optional for Step 6: If no resistance is felt with aspiration of blood and CVC locking solution, attach a 5- to 10-mL syringe of 0.9% normal
saline and flush lumen using turbulent flushing technique.
Step 7b
: Initiate dialysis.
Step 8: Discard the syringe and used materials.
Suggested Method to Disconnect CVC
Step 1: Explain the procedure to the patient, retransfuse patient’s blood as per unit protocol, perform hand hygiene, and prepare supplies for CVC
locking.
Step 2: Close the clamp on the CVC lumens and bloodlines. Disconnect 1 bloodline from 1 CVC lumen and clean the CVC hub.c
Step 3: Attach a 5- to 10-mL syringe with 0.9% normal saline to CVC lumen, unclamp CVC, and flush lumen.
Step 4: Remove normal saline syringe from lumen, attach syringe with CVC locking solution to lumen, and instill locking solution volume as per unit
CVC care protocols.d
Step 5: Close clamp on lumen, remove syringe, clean the hub, and apply sterile Luer lock cap.
Step 6: Repeat steps with second lumen.
Step 7: Discard used supplies.
Abbreviation: ANTT, aseptic no touch technique; CVC, central venous catheter.
a
If limbs do not aspirate or flush freely, ensure clamps are open and rule out external causes of resistance (kink in CVC limb or patient position).342
If
problems persist, the CVC may indicate fibrin or thrombus formation or CVC tip malposition (Guidelines 22 and 24). A gentle back-and-forth motion
(irrigate) may promote CVC patency. After irrigation, flush lumen (eg, with 10 mL of normal saline) using turbulent flushing technique to ensure that blood
is cleared from the CVC lumen (optimize line patency). Observe for bleeding if anticoagulant (locking) solution cannot be removed (aspirated).
b
If line reversal is necessary to initiate dialysis treatment, follow unit protocols and practices for next steps. If patency is established, initiate dialysis.
c
Follow “scrub-the-hub” protocol.297
d
Locking solutions may include anticoagulants, antiseptic/antibiotic, or thrombolytic locks and their combinations. Caps must be replaced every time
the catheter is accessed and de-accessed. If closed-system, high-flow needleless caps are used, follow unit protocols and manufacturer’s
recommendations.
Guideline 11. Vascular Access Use
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S77
It is recommended that the aseptic no-touch technique
(see http://antt.org/ANTT_Site/home.html) be practiced
when accessing and de-accessing the CVC and that 1 lumen
be accessed at a time to reduce the time blood remains in
the lumen (Table 11.2).
Care of Hemodialysis Central Venous Catheters
and Patient Education
To facilitate CVC care, the following actions should be
strongly considered4
:
1) Educate patients (see following), health care personnel,
and relevant administrators regarding the acceptable
appropriate indications for CVC use (Guideline
Statements 1 and 2.2) and proper procedures for safe
and optimal CVC care and use, including prophylactic
measures for CVC-related infections.
2) Periodically assess knowledge of and adherence to
guidelines for all individuals (including patients and
relevant family/patient supporters) involved in CVC
access, use, and maintenance.
3) Designate only trained individuals who demonstrate
competence for the access, use, and maintenance of
CVC.Patient teaching and instructions should include,
but are not limited to, the importance of the following:
 Initial CVC care, including when sutures should be
removed
 Frequent hand washing
 Avoid pulling, tugging, or using sharp objects (eg,
scissors) around the catheter
 What to do if the dressing becomes soiled or wet
 What to do if bleeding occurs
 What to do if the CVC falls out
 What to do if a limb clamp breaks and falls off
 What to do in the case of pain, fever or chills, or
redness or discharge seen at the CVC exit site or
tunnel
 Whom to call with questions or concerns, with the
correct contact details
Patients should be provided written instructions on CVC
care and up-to-date contact information for reporting any
vascular access concerns such as bleeding or signs of
infection (fever, chills, and/or purulent discharge).
Implementation Considerations
 The concern of the often rapid turnover of dialysis
technicians, leading to inadequate training and/or
competency to care of all types of vascular access
 The use of any intraluminal or extraluminal cleansing
solutions, antiseptics, antibiotics, medicines, or anticoagulants
should be compatible with the CVC material
 Provision of training, auditing, and feedback for
frontline staff with respect to CVC care, connection, and
disconnection procedures
Monitoring and Evaluation
 Monitor for CVC exit site healing
 The Centers for Disease Control and Prevention (CDC)
Audit and Checklist343
may also be helpful
Future Research
 Study whether sterile gloves are required if strict notouch
technique is used for CVC manipulation and care
 Study whether masks are required for each CVC dressing
change and manipulation, if the patient has head turned
away and both patient and provider do not talk.
Exception is if patient or provider has respiratory signs/
symptoms.
 Determine if there is benefit of topical barriers after exit
site and tunnel are fully endothelialized and healed.
 Validate tests to determine exit site healing
 Determine if a patient can safely shower when the exit
site and tunnel are fully healed
 Determine if a patient can safely eliminate the use of
dressings altogether when the exit site and tunnel are
fully healed, if the patient properly cleanses
Guideline 12. AV Access Cannulation
Complications
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: AV Access Cannulation Complications
12.1 KDOQI considers the following therapeutic interventions
for cannulation injury reasonable to
follow:
 Any size infiltration: apply ice for a minimum
of 10 minutes and refrain from maximizing
the blood pump speed. (Expert Opinion)
 If the infiltration is moderate, the needle
should be withdrawn and manual pressure
held over the infiltration site. (Expert Opinion)
 If the infiltration is significantly large, in
addition to the above, a decision on the necessity
for dialysis that day is required—if
dialysis is required, a site proximal to the
infiltration injury should be cannulated; if
this is not possible, reattempt at the area of
injury should not proceed until manual
pressure and ice is applied for 30 minutes.
(Expert Opinion)
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S78 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
 If a hematoma develops, close assessment of
the site, the AV access, and the adjacent extremity
should be made, including measurement
of swelling, assessment of the presence of
flow in the AV access both proximal and distal
to the hematoma, and circulation to the associated
extremity. (Expert Opinion)
12.2 KDOQI considers it reasonable to use ultrasound
to help determine direction of flow and proper
needle placement in the AV access of select
patients as needed and performed by trained
operators, to prevent cannulation complications.
(Expert Opinion)
Rationale/Background
Despite cannulation being an integral component of the
HD procedure, there is very limited evidence to support
practice. Knowledge, skill, and ability among cannulating
nurses/dialysis personnel varies significantly across jurisdictions,
with little to no minimum standards or standardization.
Basic knowledge of vascular anatomy, patientcentered
care, and the importance of provider-patient
therapeutic relationships should be components of all
cannulation training programs to reduce the frequency of
complications. The complications that occur as a result of
cannulation not only cause significant discomfort and
distress to patients but, in some cases, may negatively
affect their ability to have a functioning dialysis access in
the future. For example, a single infiltration injury that
occurs before successful 2-needle cannulation is associated
with 56% lower odds of overall AVF maturation.158
Infiltration injury is associated with frequent imaging,
interventions, and prolonged need for a CVC.3
Indeed,
unsuccessful cannulation attempts are associated with
poorer AVF maturation success and outcomes.158
Currently, complications related to cannulation are not
consistently or well documented as part of the dialysis
treatment.
Cannulation site bleeding can usually be corrected by
direct pressure but occasionally requires the placement of a
skin suture. Pressure should be applied directly to the
bleeding site, and care should be exercised not to occlude
the AV access outflow distal to the bleeding site because of
the potential to increase the intraluminal AV access pressure
to arterial levels. A “bad stick” that results in a significant
hematoma often requires placement of a CVC and
deferral of further AV access cannulations until the hematoma
is resolved, a period that may last up to 3
months.3
Bleeding from a vascular access needle site that
needs a skin suture or results in a very large hematoma is
very suggestive of a venous outflow stenosis and requires a
referral for a diagnostic angiogram.
Detailed Justification
Complications and Management
 Infiltration of the vein can occur when a needle is
inserted and the tip is inadvertently advanced beyond
the vein, perforating the side or back wall and resulting
in some degree of swelling, bruising, and/or pain.
 Hematomas can develop as a result of an infiltration of
the vein or due to leaking of blood around the puncture
site during cannulation, during a dialysis treatment, or
after removal of a needle at the end of a dialysis treatment.
The size of hematomas can vary significantly,
from a small diffuse area to a large, firm mass that can
potentially compress the vessel, resulting in thrombosis
of the AV access. The development of significant hematomas
can also result in the development of stenosis
at the site of hematoma. Every effort should be made to
avoid these.
 Pain of various degrees is common and can occur in
various sites, at various times, and with various intensity.
Pain can develop at the time of cannulation,
during the dialysis treatment at the site of or surrounding
a site of cannulation, or along the arm or
hand and continue after dialysis as a result of a hematoma,
infiltration of the vein, or irritation of an
adjacent nerve.
 Management of cannulation complications such as
infiltration and resulting hematoma is dependent on
the extent of swelling, pain and patient anxiety. The
sharing of knowledge and providing support to the
patient and family cannot be minimized. Providing
comfort measures and/or analgesic administration
must be assessed on an individual basis.
Prevention of Cannulation Complications
 AV access check or assessment before cannulation is
required. Ensuring that flow is present in the AV access
and determining the direction of flow to ensure
optimal dialysis is required before needle placement.
Observation of the full AV access and adjacent limb and
auscultation and palpation along the AV access can
detect many defects and aid in appropriate selection of
sites for cannulation. The use of bedside ultrasound by
a trained operator to aid in cannulation has been
associated with an increase in nurse confidence and
patient comfort and can help determine direction of
flow within the AV access, but there is limited evidence
at this point to recommend use in all patients. Please
see Special Discussions under Guideline 11 for
discussions about the use of ultrasound to aid
cannulation.
 Appropriate selection of cannulation sites based on
assessment and input from patients can help avoid
associated complications.
Guideline 12. AV Access Cannulation Complications
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S79
 Use of experienced cannulators to cannulate AV accesses
at risk of complications should be attempted whenever
possible. Cannulators should determine at the time of
assessment if they anticipate any challenges with cannulation
and seek expert advice and guidance. If a
cannulator is unsuccessful cannulating an AV access, a
maximum of 2 attempts is recommended before
seeking expert advice.
 The use of smaller-gauge and Teflon needles should be
considered when cannulating smaller and more fragile
vessels. Although these needles may limit blood flow,
consideration of longer, more frequent, or individualized
prescription based on the patient’s dialysis needs
and goals may enable noncomplicated use of the AV
access and avoid insertion of a CVC.
 When appropriate and possible, self-cannulation in
well-trained patients may be beneficial.
 Documentation of complications of cannulation should
be reviewed as part of each cannulator’s training and
evaluation.
Special Discussions
 Centers with limited opportunities for staff to cannulate
dialysis accesses face particular challenges. Accessing
online resources and expertise should be considered to
ensure the provision of adequate care to patients.
 The Work Group acknowledged that there is limited
evidence to support the recommendations related to
cannulation and management of cannulation-related
complications, limiting them to Expert Opinion only.
Even when reviewing the literature in areas such as
peripheral venipuncture and arterial cannulation, the
evidence is opinion based.
 When appropriate and possible, self-cannulation in
well-trained patients may be beneficial to improving
patient comfort and reducing anxiety in cannulating the
AV access.
Future Research
 Rigorous studies examining cannulation practices,
challenges to achieving complication-free cannulation,
and strategies to mitigate barriers to successful AV access
cannulation is needed
 To study the role of cannulation complication documentation
and review whether or not it improves
quality of cannulation and AV access outcomes
Guideline 13. AV Access Flow
Dysfunction—Monitoring/Surveillance
Note: “AV access flow dysfunction” refers to clinically significant abnormalities
in AV access (AVF or AVG) flow or patency due to underlying
stenosis, thrombosis, or related pathology. This is in distinction to other
types of AV access complications.
Please refer to Box 1 to understand the evidence basis
for the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Appropriate Use of Monitoring/
Surveillance for AV Access Flow Dysfunction
Physical Examination (Monitoring)
13.1 KDOQI recommends regular physical examination
or check of the AVF, by a knowledgeable and
experienced health practitioner, to detect clinical
indicators of flow dysfunction of the AVF. (Conditional/Strong
Recommendation, Moderate Quality of
Evidence)
See Table 13.2 for clinical indicators
13.2 KDOQI recommends regular physical examination
or check of the AVG, by a knowledgeable and
experienced health practitioner, to detect clinical
indicators of flow dysfunction of the AVG. (Conditional/Strong
Recommendation, Moderate Quality of
Evidence)
See Table 13.2 for clinical indicators.
13.3 KDOQI considers it reasonable for nephrology
trainees and health practitioners involved with
clinical HD patient care to be properly trained in
physical examination of the AV access to monitor
for and detect AV access flow dysfunction. (Expert
Opinion)
Surveillance to Facilitate Patency
13.4 There is inadequate evidence for KDOQI to make
a recommendation on routine AVF surveillance
by measuring access blood flow, pressure monitoring,
or imaging for stenosis, that is additional
to routine clinical monitoring, to improve access
patency.
Note: In other words, monitoring of vascular access is primary, while
surveillance findings are supplementary, and action should not be
based solely on surveillance findings.
13.5 KDOQI does not suggest routine AVG surveillance
by measuring access blood flow, pressure
monitoring, or imaging for stenosis, that is
additional to regular clinical monitoring, to
Guideline 13. AV Access Flow Dysfunction—Monitoring/Surveillance
S80 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
improve AVG patency. (Conditional Recommendation,
Low Quality of Evidence)
Note: In other words, monitoring of vascular access is primary, while
surveillance findings are supplementary, and action should not be
based solely on surveillance findings.
Investigation of Abnormalities Detected by Clinical
Monitoring
Please refer to Guideline Statements 15.1-15.3.
Statements: Surveillance and Pre-emptive
Intervention for AV Access Stenosis Not Associated
With Clinical Indicators
Endovascular Intervention to Improve Patency
13.6 KDOQI does not recommend pre-emptive angioplasty
of AVFs with stenosis, not associated
with clinical indicators, to improve access
patency. (Conditional Recommendation, Moderate Quality
of Evidence)
13.7 KDOQI does not recommend pre-emptive angioplasty
of AVGs with stenosis, not associated
with clinical indicators, to improve access
patency. (Conditional Recommendation, Moderate Quality
of Evidence)
Surgical Intervention to Improve Patency
13.8 There is inadequate evidence for KDOQI to make
a recommendation on pre-emptive surgical interventions
in AVFs with stenosis, not associated
with clinical indicators, to improve access
patency.
Statement: Pre-emptive Intervention for AV Access
Stenosis Associated With Clinical Indicators
13.9 KDOQI considers it reasonable for patients with
consistently persistent clinical indicators and
underlying AV access stenosis to undergo preemptive
angioplasty of their AV access to reduce
the risk of thrombosis and AV access loss. (Expert
Opinion)
Rationale/Background
In this Guideline, AV access flow dysfunction refers to clinically
significant abnormalities in AV access (AVF or AVG) flow or
patency due to underlying stenosis, thrombosis, or related
pathology. This was previously referred to as AV access
dysfunction, which encompassed many forms of dysfunction
(or abnormalities of AV access); however, the Work Group
wanted to distinguish AV access dysfunction due to
stenosis or thrombosis from other causes of dysfunction,
such as aneurysms. Thus, the terminology AV access flow
dysfunction is used in distinction to other types of AV access
complications.
AV access flow dysfunction is a common problem,
typically associated with underlying stenosis and/or
thrombosis. The development of progressive vascular access
stenosis with subsequent failure of the vascular access
contributes significant morbidity to patients and costs to
the health care system.344
The fundamental principle for
performing routine vascular access monitoring and surveillance
is to detect and correct the stenosis to minimize
or avoid reduced dialysis clearance (dialysis dose protection),
reduce the rate of thrombosis, and improve AV
access function. Indeed, vascular access function was
globally ranked as a top priority for patients and health
care providers clinically and as a research target, so much
so that it has become the core outcome measure for
vascular access clinical trials.345
Rationale for Physical Examination/Monitoring
A variety of methods have been proposed for screening the
AV access for early detection of stenosis before the AV
access becomes dysfunctional.346-351
Clinical monitoring
strategies include physical examination (inspection,
palpation, and auscultation) of the vascular access to detect
signs that suggest the presence of pathology. This monitoring
is ideally conducted when the patient is not on
dialysis. Abbreviated forms, such as the “One-Minute Access
Check” (esrdncc.org/en/resources/lifeline-for-a-lifetime/step-eight-the-one-minute-access-check/),
are rapid
and effective and can be conducted by patients and providers
before dialysis.352
Such monitoring can be supplemented
by review of routine laboratory studies regularly
obtained in the dialysis unit, dialysis adequacy (urea
reduction ratio or Kt/V, documented recirculation), difficulties
in cannulation or achieving hemostasis after needle
withdrawal, and other clinical signs. Although these
different techniques and methods are available for identifying
vascular access flow dysfunction, the scientific evidence
for the optimal methodology is lacking. A small
number of RCTs have been performed evaluating different
monitoring techniques. Dynamic venous pressure (DVP)
can be measured on most dialysis machines; however, the
utility of DVP at blood flows (Qb) of 150 to 200 mL/min
in detecting stenosis or predicting AV access thrombosis is
very limited, because DVP is dependent on a variety of
factors, such as the needle gauge and the length of the
dialysis needle.353
AV access recirculation and declines in
URR or Kt/V may help indicate AV access stenosis, but by
themselves cannot be sole indicators, because many variables
affect their measurements, and they have not been
rigorously studied. Following the trend of these monitoring
measures (URR, Kt/V, recirculation, etc) may be a
helpful accompaniment to physical examination and
should be properly studied. Physical examination of the
Guideline 13. AV Access Flow Dysfunction—Monitoring/Surveillance
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S81
AV access by an experienced individual has high sensitivity
and specificity.267,354,355
The physical examination is
easily available, requires minimal training, is cost efficient,
and takes minimal equipment and time. Several studies
have examined the use of the physical examination to
detect AV access flow dysfunction (ie, stenosis within the
AVF267,355
and AVG351,356
). The value of physical examination
(monitoring) is that if AV access flow dysfunction
is suspected with appropriate matching clinical indicators,
further investigation and preventive intervention, such as
with angioplasty, could be performed to improve outcomes
(eg, preventing thrombosis).
Rationale for Surveillance
The rationale underlying AV access surveillance is to detect
and correct stenosis within the AV access before the
development of thrombosis, to improve the patency of the
AV access by reducing the risk of thrombosis. Clinical
indicators associated with AV access stenosis (Table 13.2)
include reduced dialysis clearance without other known
cause, excessive bleeding after needle withdrawal, high
venous and arterial pressures at the prescribed blood
flow,357
and indicators on physical examination (see
earlier discussion on AV access monitoring). Surveillance
procedures, requiring specialized equipment and operator
skills, have been studied to detect stenosis before the
development of a clinical indicator. These include AV access
flow (Qa) measurement348,358,359
by a variety of
methods, including ultrasound dilution method (UDM)
and duplex ultrasound to measure Qa and visualize
anatomic abnormalities.360,361
The use of dynamic and
static venous pressure has also been used as a surveillance
tool362
; dynamic venous pressure measures are now
considered as supplementary to clinical monitoring.
Several important questions arise when considering AV
access surveillance to reduce thrombosis and improve AV
access patency: (1) What is the diagnostic value of surveillance
for detection of stenosis? (2) What are the validated
diagnostic thresholds by surveillance indicators (eg,
Qa, change in Qa/time) that accurately diagnose stenosis
that will lead to future thrombosis? (3) What factors, other
than stenosis, contribute to abnormal surveillance indicators?
(4) What is the appropriate intervention when
stenosis is detected by surveillance in the absence of
Table 13.1. Routine AV Access Monitoring by Physical Examination
Exam Steps Fistula (Normal) Graft (Normal)
Flow-related Dysfunction or
Poor Maturation (Abnormal)
Infection, Steal Syndrome, or
Aneurysm/Pseudoaneurysma
(Abnormal)
Look Well-developed main venous
outflow, no irregular/dilated areas
or aneurysm formations, adequate
areas of straight vein that can be
used for 2-needle, rope-ladder
cannulation
Vessel collapses when arm is
elevated above head
Uniform-sized graft in a
loop or straight
configuration
No irregular areas or
aneurysm or seroma
formations with organized
site rotation used for
cannulation
AVF with poor
maturation—multiple venous
outflow veins (accessory veins),
poorly defined cannulation
areas
AVF:
Stenosis can occur in artery or
any venous outflow vein
Look for a narrowing of the
outflow vein, abnormal
pulsations, or aneurysm
formations
AVF or AVG:
Dilated neck veins or surface
collateral veins in the arm or
neck above the vascular access
Infection:
Redness, swelling, induration,
drainage, or pus
Steal syndrome:
Extremity/hand discoloration, skin
ulceration due to poor arterial
blood flow to the hand
Check nail beds, fingers and hand
for unusual skin changes
Aneurysm
Abnormal areas of dilatation with
overlying skin thinning
Listen with a
stethoscope
Low-pitch continuous diastolic
and systolic
Low-pitch continuous
diastolic and systolic
High-pitch discontinuous
systolic only
Steal syndrome
AVF may have a very strong bruit
Feel with
your fingers
Thrill at the arterial anastomosis
and throughout the entire outflow
vein that is easy to compress
Thrill strongest at the
arterial anastomosis but
should be felt over entire
graft and be easy to
compress
AVF:
Pulse at the site of a stenotic
lesion—may be water-hammer
in quality and feel
AVG:
Thrill and/or pulse strong at the
site of stenotic lesion pulse has
a water-hammer feel
An AVG with a low intra-access
blood flow feels mushy
Local area of the graft that feels
mushy or irregular in shape can
be a site of aneurysm formation
Infection
Warm or painful to touch, swelling
Steal syndrome
Feel bilateral limbs (hands and
fingers) and compare for the
access limb to be the same as the
nonaccess limb
Compare temperature, grip
strength, and range of motion and
any complaints of changes in
sensation or pain
If the access limb has any major
differences than the nonaccess
limb, consider steal syndrome
Abbreviations: AVF, arteriovenous fistula; AVG, arteriovenous graft.
a
Also see Guidelines 16 through 19 for specific complications.
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S82 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
clinical indicators? and (5) What is the AV access patency
outcome after intervention of stenosis not associated with a
clinical indicator, and does this differ from intervention of
stenosis detected by clinical examination?
What Is the Diagnostic Value of Surveillance for
Detection of Stenosis?
Surveillance methods can detect stenosis; however, there
are valid issues regarding the accuracy and reproducibility
of this detection, which may vary based on the
method of surveillance and the indicator used. Stenosis
within the AV access is thought to be reflected by reductions
in AV access flow and alterations in AV access
circuit pressures. However, flows and pressures are
influenced by factors other than the presence of stenosis,
including the location and degree of the stenosis,
variations in the hemodynamics over the course of
dialysis (eg, timing, blood pressure), and cannulation
technique and AV access characteristics.362-364
Thus,
repeat measurements and trending of surveillance results
are important to confirm abnormal surveillance results,
if surveillance is done. The location of the stenosis can
influence the diagnostic characteristics of the surveillance
tool, and an AV access can have multiple stenoses,
not reliably detected with a single surveillance tool,
especially if measured in isolation.365
Additionally, the
AVG and the AVF have different pathophysiology for
development of stenosis, occurring at different rates, at
different locations, and with different hemodynamic
consequences based on their configurations.366
What Are the Validated Diagnostic Thresholds by
Surveillance Indicators (eg, Access Flow Rate,
Change in Access Flow Rate) That Accurately
Diagnose Stenosis That Will Lead to Future
Thrombosis?
The various surveillance techniques available to detect AV
access stenosis differ in their ability to accurately and
reliably detect AV access flow dysfunction beyond clinical
examination.13,367
In addition, when using a given surveillance
method to detect significant stenosis that would
prompt intervention, there is still a need for standardized
diagnostic thresholds with sufficient sensitivity to detect
clinically significant stenosis but with good specificity to
avoid unnecessary interventional procedures. Issues
regarding surveillance reliability and reproducibility (see
above) add to the challenge of defining and validating
diagnostic thresholds. As such, the required validated
thresholds for intervention have not been established for
all methods of AV access surveillance.
What Factors, Other Than Stenosis, Contribute to
Abnormal Surveillance Indicators?
Variables to consider (discussed above) include factors
related to the hemodialysis procedure, patients’ response
to it (eg, hypotension), the AV access, and AV access circuit
anatomy and physiology.362,363
In addition, the
expertise and reliability of the operator obtaining the
measurement may contribute to abnormal surveillance
indicators.
This Guideline focuses on the evidence available, or the
lack thereof, for answering the remaining patientimportant
and clinically relevant questions (4) and (5):
What is the appropriate intervention when stenosis is
detected by surveillance in the absence of clinical indicators?
and What is the AV access patency outcome after
intervention of stenosis not associated with a clinical indicator,
and does this differ from intervention of stenosis detected
by clinical examination?
The brief answers are as follows:
What is the appropriate intervention when stenosis
is detected by surveillance in the absence of clinical
indicators? Do nothing—do not intervene in the absence
of clinical indicators.
What is the AV access patency outcome after intervention
of stenosis not associated with a clinical indicator,
and does this differ from intervention of stenosis detected
by clinical examination? (1) For AVF, the data are unclear
and more study is required; (2) for AVG, the data do not
demonstrate improved patency with surveillance and subsequent
pre-emptive intervention on AVG with no clinical indicators,
compared with routine clinical examination.
Table 13.2. Clinical Indicators (Signs and Symptoms) Suggesting Underlying Clinically Significant Lesions During Access Monitoring
Procedure Clinical Indicators
Physical examination or
check
 Ipsilateral extremity edema
 Alterations in the pulse, with a weak or resistant pulse, difficult to compress, in the area of stenosis
 Abnormal thrill (weak and/or discontinuous) with only a systolic component in the region of stenosis
 Abnormal bruit (high pitched with a systolic component in the area of stenosis)
 Failure of the fistula to collapse when the arm is elevated (outflow stenosis) and lack of pulse augmentation
(inflow stenosis)
 Excessive collapse of the venous segment upon arm elevation
354,365
378
239
360
267
Dialysis  New difficulty with cannulation when previously not a problem
 Aspiration of clots
 Inability to achieve the target dialysis blood flow
 Prolonged bleeding beyond usual for that patient from the needle puncture sites for 3 consecutive dialysis
sessions
 Unexplained (>0.2 units) decrease in the delivered dialysis dose (Kt/V) on a constant dialysis prescription without
prolongation of dialysis duration
379
239
360
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Detailed Justification
The 2006 KDOQI Vascular Access Work Group previously
recommended AV access surveillance with preemptive
angioplasty of stenosis to improve AV access
outcomes.13
This was based on the best available evidence
at that time that supported the premise that use of
surveillance for the early detection of AV access stenosis
and its preemptive correction compared with deferred
correction would improve AV access outcomes. There
has been controversy over the interpretation of this
recommendation based on previous and more current
evidence. Over time, the nephrology community has
recognized that surveillance for stenosis in isolation is not clinically
meaningfully without also examining the effect of the subsequent
intervention on clinically important outcomes, which, in this
case, would include AV access thrombosis, patency, and
intervention rates. Many studies have been underpowered
to show either benefit or harm from surveillance
strategies. Multiple factors discussed earlier contribute to
the heterogeneity of the results and interpretations of
the studies in this area and have contributed to the
change in the recommendations for AV access
surveillance.
Physical Examination
The physical examination is easily available, requires
minimal training, is cost efficient, and takes minimal
equipment and time. Several studies have examined the use
of the physical examination to detect AV access flow
dysfunction (eg, stenosis within the AVF13,364,365
and
AVG361,362
).
Diagnostic Accuracy of the Physical Examination to
Detect Stenosis in the AVF. Two observational studies
compared physical examination with angiography for
monitoring and diagnosing dysfunction with AVF.267,354
Coentrao et al354
analyzed data resulting from physical examinations
by 11 general nephrologists and 1 nephrology
resident who received 6 months of training on conducting
physical examinations to identify AV access flow dysfunction.
Diagnostic physical examination results were
compared with those of angiography for detecting AV access
stenosis. Clinical criteria for AV access flow dysfunction
prompting angiography were applied according to the prior
2006 KDOQI guideline.13
Physical examination included
inspection of the arm, chest, neck, and face; palpation of the
entire AVF tract; arm elevation; pulse and thrill abnormalities;
and pulse augmentation tests. AVF dysfunction was
classified into 4 major disorders: inflow stenosis, outflow
stenosis, coexisting inflow/outflow stenosis and AVF
thrombosis. Stenosis by angiography was defined as 50%
luminal narrowing compared with the normal vascular
segment located adjacent to the stenosis according to 2006
KDOQI guideline.13
Thrombosis of the AVF was ascertained
by the presence of clots in the arterial and/or venous sides
of the AVF. The agreement beyond chance between the
nephrologists’ physical examination and angiography for
the assessment of AVF dysfunction was moderate (kappa =
0.49; 95% CI, 0.40-0.57). and near-perfect when the
physical examination was done by the trained nephrology
resident (kappa = 0.86; 95% CI, 0.77-0.95). The agreement
was similar for both forearm and upper arm AVFs.
Asif et al267
(n = 147) compared results of a complete
physical examination of the AV access conducted by an
interventional nephrologist to angiography. Similar criteria
for AV access flow dysfunction were used as in the
Coentrao et al study.354
The diagnostic accuracy of physical
examination was poor for central vein and AVF body stenosis,
moderate for inflow and coexisting inflow and
outflow stenosis, and good for outflow stenosis.
Diagnostic Accuracy of the Physical Examination to
Detect Stenosis in the AVG. Leon et al356
conducted preprocedure
physical examinations on 43 consecutive patients
referred for angiography to manage AVG dysfunction.
Physical examination findings and diagnosis were
each recorded and secured in a sealed envelope. Angiography
from the feeding artery to the right atrium was
performed. The angiographic images were reviewed by an
independent interventionalist with expertise in AV access
procedures who was blinded to the physical examination
results. The agreement beyond chance between physical
examination and angiographic findings was strong for the
diagnosis of vein-graft anastomotic stenosis (kappa =
0.52) and moderate for intragraft stenosis (kappa = 0.43)
and inflow stenosis (kappa = 0.40). The findings of this
study demonstrate that physical examination can assist in
the detection and localization of stenoses in AVGs.
Surveillance
Surveillance of the AVF. The use of physical examination
is an accepted, standard, evidence-based practice for the
assessment and monitoring of the AV access for access flow
dysfunction, infection, and vascular integrity. Only 1 study
compared the addition of surveillance methods to routine
clinical examination for detecting stenosis and reported AVF
outcomes, with variable results, depending on the type of
surveillance and outcome examined.368
The need to address whether or not surveillance
methods can detect AVF dysfunction and stenosis and its
incremental benefit beyond clinical examination (monitoring)
is important to focus efforts for education,
training, and the attainment of expertise in the relevant
method for detecting AVF flow dysfunction.
Clinical Monitoring Plus Blood Flow (Qa) Surveillance
Versus Clinical Monitoring Alone. A single-center
RCT (n = 137) of AVF surveillance compared clinical
monitoring plus intra-access blood flow (Qa) surveillance
using UDM versus clinical monitoring alone.347
The clinical
monitoring group was referred to angiography if stenosis
was clinically suspected. Participants in the UDM Qa
surveillance group were referred to angiography if stenosis
was clinically suspected or Qa was <500 mL/min at baseline
or if Qa fell by >20% once Qa was <1,000 mL/min.
Patients in the UDM Qa surveillance group were twice as
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S84 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
likely to have stenosis detected compared with those in the
clinical monitoring alone group (HR, 2.27; 95% CI, 0.85-
5.98; P = 0.09 [NS]), with a trend for the stenosis to be
detected earlier in the UDM Qa surveillance group. The area
under the curve demonstrated moderate prediction of
>50% stenosis (0.78; 95% CI, 0.63-0.94; P = 0.006) in the
UDM surveillance group. The study primary outcome was
the time to detection of an angiographically significant AVF
stenosis (defined as a ≥ 0% reduction of the normal vessel
luminal diameter on angiography accompanied by a hemodynamic
[in the case of the Qa surveillance group],
functional, or clinical abnormality [in the case of the control
group]) was not significantly different with clinical
monitoring plus UDM Qa surveillance versus clinical
monitoring alone (P = 0.20).
In summary, the use of surveillance methods in addition
to clinical monitoring in AVF appears to increase the
rate of detection of AVF stenosis and the rate of AVF
intervention.
Surveillance of the AVG. Several previous studies have
examined the effect of surveillance in addition to clinical
monitoring in AVG.351,360,364,369
Most of the studies did not
specifically examine the rate of detection of stenosis but,
rather, a clinical outcome of thrombosis or patency. The ERT
did not include these studies because their publication dates
were outside the prespecified window of dates for data
extraction. However, the Work Group believed it was
important to discuss previous studies that examined clinical
monitoring alone and clinical monitoring plus surveillance in
AVGs.
One blinded RCT (N = 112) compared clinical monitoring
(DVP and physical examination) plus monthly Qa
measurement by UDM versus clinical monitoring alone.351
The Qa surveillance group was referred for angiogram if Qa
was <650 mL/min or there was a 20% decrease in Qa from
baseline, whereas the clinical monitoring alone group were
referred for significant changes in dialysis adequacy or
physical examination or for high DVP. Percutaneous angioplasty
was performed for stenosis ≥50% compared with
the adjacent vessel. The rates of AVG thrombosis per
patient-year at risk were 0.51 and 0.41 in the surveillance
and clinical monitoring groups, respectively (P = 0.57).
Stenosis was detected more frequently in the surveillance
group because of the increased use of angiograms and was
accompanied by an increase in interventions: 51 interventions
(0.93/patient-years at risk) in the Qa surveillance
group versus 31 interventions (0.61/patient-years at
risk) in the clinical monitoring alone group.
In summary, the use of surveillance methods in addition
to clinical monitoring in AVG appears to increase the
rate of detection of AVG stenosis and the rate of AVG
intervention.
Surveillance and Preemptive Repair
The aim of interventions to prevent AV access flow
dysfunction (ie, to improve patency or access function) is
to improve patient and vascular access outcomes, with
greater net benefit than harm, compared with no interventions
(see the Background/Rationale for this section).
There is limited evidence to provide guidance on the
role of appropriate methods to prevent clinically insignificant
stenosis (ie, stenosis that may be associated with
abnormal findings on surveillance but without accompanying
clinical indicators) in AVFs and AVGs. The available
literature for AVF and AVG is provided in subsequent
sections.
Surveillance and Preemptive Repair in Asymptomatic
AVFs. One observational study using data from the Fresenius
Medical Care North America centers (N = 35,716)
compared elective percutaneous angioplasty (PTA) with no
treatment for the prevention of AVF and AVG (AV access)
dysfunction. Patients were referred for PTA based on Qa
of <400 mL/min or change >30% for AVF and <600 mL/
min for AVG. In the AVF subgroup, patients who received
angiography and PTA were matched to control individuals
not receiving an intervention (matched on vascular access
type, access age, intra-access blood flow rate using the
method of ionic online clearance, and single-pool Kt/V).
Follow-up was for 1 year after intervention with angiography
and PTA. The key findings are370
(1) secondary
patency was not significantly different with elective angiography
and PTA versus no treatment and (2) thrombosis
was not significantly different with elective PTA versus no
treatment. The primary outcome was 1-year AV access
survival (cumulative patency) from the date of first intervention,
and it was not significantly different with elective
PTA versus no treatment (54.8 vs 47.8 per 100 access years;
HR, 1.06; 95% CI, 0.98-1.15). Several secondary outcomes
were evaluated. Embolism with upper-arm thrombosis was
not significantly different with elective PTA versus no
treatment for AVF and AVG combined (0.86% vs 0.03%
events per procedure; attributable risk increase, 0.83%;
95% CI, 0.56-1.12). This outcome was not reported
separately by AV access type. Other harms were not reported
for this comparison.
In contrast, a prospective study was conducted in patients
who did not meet prior KDOQI Qa criteria for
intervention but had abnormal clinical monitoring findings, for
example, on physical examination. A single open RCT of
AVFs (n = 58) assessed AVF with subclinical stenosis and
Qa >500 mL/min (but abnormal physical examination
result, Qa of <900 mL/min and elevated static venous
pressure) who had prophylactic repair (pre-emptive
intervention group) versus observation (repair at the time of
AVF thrombosis).349
Subclinical stenosis was angiographically
defined as >50% reduction in vessel diameter
compared with the adjacent segment. Prophylactic repair in
the pre-emptive intervention group was by either PTA or
surgery, whereas the observation arm underwent stenosis
repair only after the onset of AVF dysfunction (defined as
clinical abnormality) or a Qa of <400 mL/min (n = 3). AVF
loss was lower in the pre-emptive PTA group than the
Guideline 13. AV Access Flow Dysfunction—Monitoring/Surveillance
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S85
observation alone group: 5 (18%) versus 13 (43%),
respectively (corresponding AVF loss rates [event/AVF-year]
were 0.066 and 0.186; P = 0.041). Thrombosis rates were
significantly lower in the pre-emptive PTA group than
observation alone group: 21% versus 50%, respectively. The
use of temporary CVC and associated CVC infection rates
were not significantly different between groups.349
In addition to the described studies extracted by the
ERT, when finalizing the KDOQI guideline statements, the
Work Group considered other RCTs347,348,371,372
in this
area outside the prespecified window of data extraction.
The Work Group believed that these previous RCTs help
place the reported data in the appropriate context. There is
further discussion about these specific studies in the
“Special Discussions” section that follows.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S132, S134-S138, S145,
and S147-S151.
Surveillance and Preemptive Repair in Asymptomatic
AVGs. There was 1 RCT (N = 64) in AVG comparing preemptive
intervention of asymptomatic stenosis versus observation
(repair at the time of thrombosis).373
AVGs with
elevated static venous pressure values underwent diagnostic
angiography. If there was a stenosis producing at least a 50%
reduction in lumen diameter and the static venous pressure
ratio was ≥0.4, patients were then randomized to the preemptive
intervention arm (prophylactic repair by PTA) or
surgery (if PTA was unable to be performed or was unsuccessful).
The observation arm had intervention only after an
AVG thrombosis event or if there was clinical evidence of AVG
dysfunction. Participants were followed for 3.5 years. Mortality
(19% in the pre-emptive intervention arm and 13% in
observation arm), AVG loss (14 patients [44%] in each arm),
and time to AVG abandonment did not differ between groups.
The rates of thrombosis were significantly lower with preemptive
intervention than with observation (44% vs 72%).
Dember et al373
reported no other differences between
groups.
In AVGs, 1 observational study by Chan et al370
(N =
35,716), used data from the Fresenius Medical Care North
America centers to compare elective angioplasty versus no
treatment for prevention of AVF dysfunction (described
earlier) but also included a subset of patients with AVG who
had elective angioplasty versus no treatment. Similar to the
AVF cohort, in AVGs, follow-up was for 1 year after intervention
with angiography and PTA. This study had these
main findings: (1) secondary AVG patency was not significantly
different with elective angiography and PTA versus no
treatment and (2) thrombosis was not significantly different
with elective angioplasty versus no treatment. The primary
outcome was 1-year access survival (cumulative patency)
from date of first intervention and was not significantly
different with elective PTA versus no treatment (51.7 vs 52.7
per 100 access years; HR, 0.95; 95% CI, 0.86-1.05).
Similar to our discussion in the earlier AVF section, in
addition to the described studies extracted by the ERT,
when finalizing the KDOQI guideline statements, the Work
Group considered other RCTs351,360,373-376
in this area
outside the prespecified window of data extraction. The
Work Group felt that these previous RCTs help place the
above data in the appropriate context. There is further
discussion about these specific studies in the “Special
Discussions” section that follows.
In summary, in clinical practice, many centers use surveillance
techniques with the intention to detect early
dysfunction in AVF and AVG with the premise that early
identificationandcorrectionofstenosismaypreventclinically
significantdysfunction,suchasathromboticevent.However,
in clinical practice, it is difficult to predict which stenosis
(anatomic abnormality) will progress into a clinically significant
functional abnormality, such as an occlusive throm-
bosis.Interveningonstenosesthatareclinicallyasymptomatic
may lead to unnecessary interventions, and, subsequently,
more interventions to maintain patency—which does not
appear to be improved with pre-emptive intervention.373
Thus, given the evidence available from the literature, our
recommendations are to intervene only on AVFs and AVGs
that have clinically relevant dysfunction when detected on
routine clinical monitoring (eg, abnormal physical examination
findings, low Kt/V without other cause, persistently
inadequate blood flow rates to provide prescribed dialysis
without other cause than the AV access, high venous pressure
during dialysis, etc) We do not recommend interventions in
AVG and AVFs that do not have clinically significant
dysfunction (Supplement 3, Tables S133, S139, S140-S144,
S146, and S152-S156).
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S110-S156.
Special Discussions
Overall, there were very few studies that evaluated methods
to prevent AVF and AVG dysfunction that were of highquality
evidence, per ERT. The Work Group discussed
and considered previous RCTs347,348,351,360,371,373-377
not
included in the data extraction (Table 13.3) in developing
the guidelines and determined that these previous RCTs
were important in the overall context of developing the
guideline statement. Only 1 previous study demonstrated
improved longevity with surveillance in AVGs,376
with
the remaining studies showing no statistical benefit
compared with clinical monitoring in improving
thrombosis or cumulative survival. In AVFs, several
studies showed benefit of surveillance techniques
compared with clinical monitoring; however, they too,
had methodologic concerns (eg, group contamination,
generalizability).
The Work Group recognizes that duplex ultrasound is
valuable and has different characteristics than specific
surveillance techniques for intra-access flow; however, the
ERT evidence was limited. The Work Group encourages
further research in all monitoring and surveillance techniques
and strategies (see Future Research in this section).
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S86 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
There was no evidence-grade literature on evaluating
multidisciplinary care in the prevention of AV access flow
dysfunction (primary and secondary prevention). However,
given that a multidisciplinary effort is essential to
achieve a successful vascular access, including disciplines
such as nephrology, surgery, interventionalist, and dialysis
nursing, a multidisciplinary team is also likely crucial to
identifying clinically important AV access flow dysfunction,
referring for intervention, and proceeding in a timely
manner, if necessary.
Implementation Considerations
A multidisciplinary program comprising nephrologists,
surgeons, interventionalists, vascular access coordinators,
and dialysis nurses to provide coordinated care is likely
essential to prevent asymptomatic AV access complications.
Development of curriculum is necessary for implementation
into training programs for nephrology fellows and
health practitioners evaluating and caring for the AV access.
Monitoring and Evaluation
Important considerations when implementing new
monitoring and surveillance programs include considering
the processes of care and practice patterns at each individual
dialysis center, because monitoring and surveillance
may be different. Thus, changes in implementation of
monitoring or surveillance within a dialysis unit may affect
usual established protocols.
Table 13.4. Performance and Agreement Beyond Chance Between Physical Examination and Ultrasonography
Complete PE Edema AVF collapse Thrill Pulsatility
True positive, n 47 1 41 19 40
True negative, n 28 42 12 30 28
False positive, n 14 0 30 12 14
False negative, n 10 56 16 38 17
Sensitivity, % (95% CI) 82 (72-93) 2 (0-6) 71 (59-84) 33 (20-47) 70 (57-83)
Specificity, % (95% CI) 67 (51-82) 100 (99-100) 29 (14-43) 71 (57-86) 67 (51-82)
PPV, % (95% CI) 77 (66-88) 100 (50-100) 57 (45-69) 61 (43-80) 74 (61-87)
NPV, % (95% CI) 74 (58-89) 43 (33-53) 43 (23-63) 44 (32-57) 62 (47-78)
LR+, % (95% CI) 2.47 (1.59-3.86) — 1.00 (0.78-1.29) 1.17 (0.64-2.13) 2.11 (1.33-3.33)
LR-, % (95% CI) 0.26 (0.14-0.48) 0.98 (0.95-1.02) 1.00 (0.53-1.88) 0.93 (0.72-1.22) 0.45 (0.28-0.70)
Overall accuracy,
% (95% CI)
76 (67-85) 43 (33-54) 46 (36-57) 51 (40-61) 69 (59-78)
κ (95% CI); P value 0.5 (0.32 to
0.67); <0.001
0.02 (-0.02 to 0.04);
0.388
-0.25 (-0.4 to 0.1);
0.956
-0.05 (-0.24 to 0.14);
0.614
0.37 (0.18 to
0.55); <0.001
Note: The physical examination was performed before the HD session by a single nephrologist and was divided into 3 steps. Pulse and thrill were
evaluated following the model described by Beathard.380,381
Physical examination was considered positive for the presence of stenosis if at least 1 of
the signs suggestive of stenosis was detected regardless of the step. Stenosis was also identified by the presence of edema and collateral circulation
in AVF arm. Stenosis prevalence = 58%.
Abbreviations and definitions: κ, Cohen’s kappa coefficient (agreement beyond chance); CI, confidence interval; LR+, positive likelihood ratio; LR-,
negative likelihood ratio; NPV, negative predictive value; PPV, positive predictive value;
Reproduced from Campos et al378
with permission from John Wiley and Sons.
Table 13.3. Additional Randomized Controlled Trials of AVG Surveillance
Reference Surveillance Method
Patients, n PTA/year Thrombosis/year
Primary Outcome ResultCon Sur Con Sur Con Sur
Lumsden et al374
Doppler ultrasound 32 32 0 1.5 0.47 0.51 AVG Survival No difference
Ram et al375
1. Ultrasound dilution (monthly)
2. Duplex ultrasound (quarterly)
34 32
35
0.22 0.34
0.65
0.68 0.91 AVG Survival No difference
Moist et al351
Access flow 53 59 0.61 0.93 0.41 0.51 1. Time to AVG Thrombosis
2. AVG survival
No difference
No difference
Dember et al373
Static DVP 32 32 0.04 2.1 1.03 0.89 AVG survival No difference
Malik et al376
Ultrasound 92 97 NR NR NR NR AVG survival Benefit for surveillance
Robbin et al360
Ultrasound 61 65 0.64 1.06 0.78 0.67 AVG survival No difference
Abbreviations: Avg, arteriovenous graft; Con, control; DVP, dynamic venous pressure; NR, not reported; PTA, percutaneous balloon angioplasty; Sur,
surveillance.
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Future Research
The Work Group proposed the following topics as
important areas for further research: (1) RCTs, with
adequate methodology and power to delineate the role, if
any, of the current and future surveillance and intervention
methods, within a strategy to improve AV access patency;
(2) specific studies evaluating the impact of pre-emptive
intervention in patients with clinical indicators; (3) more
comparative studies of physical examination/clinical
monitoring and imaging studies (± surveillance methods)
in various clinical scenarios (eg, on/off dialysis) to better
define its sensitivity, specificity, predictive values, and
accuracy of detecting clinically significant lesions, to
expand on data (example of data in Table 13.4); (4)
validation of the indicators on clinical monitoring of
clinically significant stenosis; (6) consideration and proper
study of the use of new technology or methods, including
point-of-care ultrasound, to facilitate monitoring or surveillance
of vascular access; (5) identification of subgroups
of patients who may benefit from earlier angiographic
intervention; (6) indications for endovascular versus surgical
intervention; and (7) potential impact of multidisciplinary
care for improved AV access patency.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S110-S156.
Guideline 14. AV Access Flow
Dysfunction—Prevention
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Noninvasive Primary and Secondary
Prevention of AV Access Flow Dysfunction
Note: “AV access flow dysfunction” refers to clinically significant
abnormalities in AV access (AVF or AVG) flow or patency due to
underlying stenosis, thrombosis, or related pathology. This is in
distinction to other types of AV access complications.
Fistulas
14.1 KDOQI suggests that the use of adjuvant farinfrared
therapy to improve AVF primary
patency be based on individual circumstances,
feasibility, and the clinician’s best judgment and
expertise. (Conditional Recommendation, Moderate
Quality of Evidence)
14.2 KDOQI does not suggest the routine use of fish
oil or aspirin to prevent AVF flow dysfunction.
(Conditional Recommendation, Low-Moderate Quality of
Evidence)
14.3 There is inadequate evidence for KDOQI to make
a recommendation on the use of simvastatin and
ezetimibe to reduce AVF interventions or
thrombosis.
14.4 There is inadequate evidence for KDOQI to make
a recommendation on the use of clopidogrelprostacyclin
to improve AVF primary failure.
Grafts
14.5 KDOQI suggests careful consideration of potential
individual patient benefits, risks, and circumstances
prior to the use of combination
dipyridamole (200 mg) and aspirin (25 mg)
twice daily to improve AVG primary unassisted
patency. (Conditional Recommendation, High Quality of
Evidence)
14.6 KDOQI suggests the use of oral fish oil supplementation,
in patients with newly created AV
grafts, to reduce patient morbidity (ie, reduce
frequency of thrombosis and related corrective
interventions). (Conditional Recommendation, Moderate
Quality of Evidence)
14.7 There is inadequate evidence for KDOQI to make
a recommendation on the use of oral fish oil
supplementation to prolong AVG cumulative
patency.
14.8 There is inadequate evidence for KDOQI to make
a recommendation on the use of simvastatin and
ezetimibe for reducing AVG interventions and
thrombosis.
Rationale/Background
Arteriovenous Fistula
AVF maturation failure remains an important clinical
problem for HD patients and has been reported in observational
studies to range from 20% to 60%.77,233,234
In
fact, a multicenter RCT in the United States reported that
up to 60% of AVFs created failed to mature successfully for
dialysis use.31
At present, there are very few effective
therapies to prevent AVF dysfunction. The 2006 KDOQI
guideline recommended interventions in AVF in the
presence of inadequate flow to support dialysis, hemodynamically
significant venous stenosis, aneurysm formation,
and ischemia.13
These Guidelines recommended a PTA or
surgical revision in an AVF with greater than 50% stenosis
in either the venous outflow or arterial inflow, in
conjunction with clinical or physiologic abnormalities.13
The previous 2006 KDOQI guideline did not address
pharmacologic interventions to prevent AVF dysfunc-
tion.13
Since the 2006 KDOQI guideline, there has been
newly published literature evaluating pharmacologic and
other therapies to prevent AVF dysfunction.
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S88 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Far-Infrared Therapy. Four studies (N = 763), all
conducted in Taiwan, compared far-infrared radiation
with no treatment for prevention of AVF dysfunction.382-
385
One study recruited patients not yet on HD for
whom a new AVF was created,384
2 studies recruited patients
already on HD via AVF for at least 6 months without
AVF interventions for at least 3 months,382,383
and 1
recruited patients on HD via AVF who required 2 or more
percutaneous interventions in the past.385
Participants
were followed for 1 year. All 4 and the pooled results
reported statistically higher rates of primary patency at 1
year with far-infrared radiation compared with no treatment
(RR, 1.24; 95% CI, 1.07-1.45). Lin et al384
in 2013
reported significantly lower occlusion in the far-infrared
radiation group (5%) versus no treatment group (18%)
(P = 0.03). Lin et al382
in 2007 found no difference in
thrombosis at 1 year (P = 0.15).
There was no difference in the need for angioplasty
between treatment arms; Lin et al382,383
in 2013 reported
angioplasty in 23% versus 25% (P = 0.87). In another study,
Lin et al384
reported 0.11 versus 0.29 angioplasties per day
per patient per year (P = 0.10). Lai et al385
and Lin et al384
reported no complications or infections in both groups. Lin
et al384
reported shorter hospital stays with the far-infrared
radiation versus no treatment (0.40 vs 1.35 days/patient/
year; P < 0.01) (Supplement 3, Tables S157 and S158).
Fish Oil. A single RCT by Irish et al386
(N = 567)
compared fish oil versus placebo for prophylaxis of AVF
dysfunction. A subset of participants in both groups
without indication for aspirin (n = 406) was also randomized
to aspirin or placebo. It is unclear how many in
each group were concurrently taking aspirin, but analyses
controlled for aspirin status. Follow-up was 6 months for
adverse events, hospitalizations/emergency department
visits, and mortality and 1 year for primary outcomes
(primary AVF failure and thrombosis). Study participants
were on average 55 years old; 63% were men, 53% were
white, and 32% were Asian (Supplement 3, Table S158).
There was no significant difference in AVF primary failure,
thrombosis, hospitalizations/emergency department visits,
or mortality (Table 14.1).
There was no significant difference in adverse events
with fish oil versus placebo for bleeding (6% vs 4%) (RR,
1.56; 95% CI, 0.72-3.39) or gastrointestinal events (both
5%) (RR, 1.06; 95% CI, 0.52-2.17).
Primary failure in this study was defined as a composite
of thrombosis, AVF abandonment, and cannulation failure.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S158-S160.
Simvastatin-Ezetimibe. Herrington et al387
conducted
a secondary analysis of the Study of Heart and Renal
Protection (SHARP) trial (N = 2,353) that evaluated the
potential impact of simvastatin and ezetimibe on
vascular access occlusive events. Vascular occlusive event was
defined as any vascular access revision procedure (PTA,
embolectomy, or surgical repair), any AV access
thrombosis event, or the removal of old/placement of
new vascular access (AV access or CVC). Analyses were
restricted to those participants known to have a preexisting
functioning AVF or AVG at randomization.387
Participants were on average 59 years old; 65% were
male and 94% had an AVF access.387
There was no
significant difference in the need for intervention with
simvastatin and ezetimibe versus placebo (19% vs 21%;
note that vascular access types were not reported separately;
RR, 0.87; 95% CI, 0.74-1.02). Access thrombosis
was not significantly different with simvastatin/ezetimibe
versus placebo (RR, 0.90; 95% CI, 0.71-1.15), nor
was the rate of any vascular occlusive event (27% for
simvastatin/ezetimibe vs 32% for placebo) (RR, 0.83;
99% CI, 0.68-1.02).387
Harms pertaining to vascular
access were not reported (Supplement 3, Tables S160-
S163).
Clopidogrel and Prostacyclin. There is 1 RCT (N =
96) by Abacilar et al283
from Turkey comparing clopidogrel
in combination with prostacyclin versus placebo to
prevent AVF dysfunction. Primary failure at up to 12
months was 8% with clopidogrel-prostacyclin therapy
versus 30% with placebo (RR, 0.82; 95% CI, 0.31-0.94).
Primary patency was not significantly different with
clopidogrel-prostacyclin therapy (60%) versus placebo
(39%) (RR, 1.53; 95% CI, 1.00-2.35). There was no
significant difference in number of adverse events
(tenderness, edema, or hematoma) (18% vs 13%,
respectively; RR, 1.38; 95% CI, 0.53-3.58) and bleeding
(RR, 0.92; 95% CI, 0.059-14.3) between arms283
(Supplement 3, Tables S160-S162). This study was discussed
at length by the Work Group. There were concerns
regarding the methodology and reporting of this study and
its potential clinical applications.
Arteriovenous Grafts
Preventing AVG thrombosis and maintaining longevity
remains a major clinical problem for HD patients.
Thrombosis can account for up to 80% of AVG fail-
ures235,236
due to an underlying stenosis at the venous
anastomosis.237-239
The 2006 KDOQI guideline recommended
evaluation and treatment in AVGs of patients with
extremity edema persisting for 2 weeks or longer, AVGs at
risk for rupture, and stenosis with a >50% decrease in
Table 14.1. Primary Outcomes for Fish Oil Versus Placebo for AVF
Outcome
Fish
Oil,
%
Placebo,
%
Relative Risk
(95% CI)
Primary failure 47 47 1.03 (0.86 to 1.23)
Thrombosis 22 23 0.98 (0.72 to 1.34)
Hospitalizations/
emergency department
38 39 0.99 (0.79 to 1.24)
Mortality 3 3 0.89 (0.35 to 2.27)
Abbreviation: CI, confidence interval.
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S89
luminal diameter with clinical and physiologic abnormal-
ities.13
These Guidelines recommended PTA or surgical
revision/repair to prevent AVG dysfunction.13
Since the
2006 KDOQI guideline, there has been newly published
literature evaluating pharmacologic therapies and novel
interventions to prevent AVG dysfunction.
Recent studies that assessed pharmacologic therapies to
prevent AVG dysfunction include those related to fish oil
and dipyridamole.97,388-390
Fish Oil. Two North American studies (N = 230)
compared fish oil with placebo for patency of AVGs. Lok
et al followed participants for 1 year388
and Bowden et al
for 8 months.389
Primary patency was better at 1 year with
fish oil versus placebo in Lok et al (48% vs 32%; HR, 0.68;
95% CI, 0.46-0.99; P = 0.045), but Bowden et al reported
no difference at 6 months (mean patency rate, 254.2 days
vs 254.1 days). Bowden et al reported the proportion of
AVG with thrombosis or required angioplasty, 50% versus
40% (RR, 1.25; 95% CI, 0.56-2.81).389
Secondary patency
was not significantly different with fish oil versus placebo.
Lok et al388
reported that time to intervention was not
significantly different with fish oil versus placebo (HR,
0.78; 95% CI, 0.55-1.09). However, fewer interventions
per 1,000 access days was reported with fish oil versus
placebo (0.39 vs 0.95 interventions per 1,000 access days;
95% CI, 0.20-0.85; P = 0.02).388
This group also reported
a lower rate of thrombosis with fish oil compared with
placebo, 1.71 versus 3.41 (RR, 0.50; 95% CI, 0.35-0.72).
Bowden et al389
reported no difference in gastrointestinal
distress between patients assigned to fish oil versus placebo,
33% versus 13% (RR, 2.68; 95% CI, 0.62-11.6). The
dose and compositions of fish oil used by Bowden and Lok
were different.
Tables of study details and evidence quality are provided
in Supplement 3, Tables S164 and S166.
Dipyridamole and Aspirin96,390
. Two publications of 1
North American RCT (N = 649) reported outcomes for the
comparison between dipyridamole (200 mg) and aspirin
(25 mg) daily versus placebo96,390
given at the time of
AVG creation and followed for 1 year. The participants
were on average 59 years old; 39% were male, and 71%
were black. Dixon et al96
showed that AVG unassisted graft
patency at 1 year was lower with dipyridamole/aspirin
(80%) versus placebo (84%) (HR, 0.82; 95% CI, 0.68-
0.98). They reported a median primary patency of 5.8
months with dipyridamole/aspirin versus 4.3 months with
placebo (ie, a difference of 6 weeks); however, statistical
significance was not reported, and data was otherwise
insufficient to calculate significance or assess quality of
evidence. There was no difference in hospitalizations between
groups (54% vs 52%; HR, 0.93; 95% CI, 0.75-
1.15).96,390
The study did not report further harms of the
dipyridamole and aspirin combination.
The study details and evidence quality are provided in
Supplement 3, Table S166.
Summary
Arteriovenous Fistula. In AVFs, clopidogrel and prostacyclin
has been the only pharmacologic therapy suggested
by RCT evidence to be effective to prevent AVF
dysfunction.283
This study reported that clopidogrel and
prostacyclin therapy improved primary AVF failure.
Although reviewed in a separate section, a multicenter RCT
by Dember et al31
reported that clopidogrel significantly
reduced 6-week AVF thrombosis but did not improve AVF
suitability for dialysis. A recent RCT evaluating fish oil and
aspirin in new AVFs did not show any benefit to improve
primary failures, thrombosis, abandonment, or cannulation
failure in the fish oil group.386
A subset of participants
without aspirin indication (n = 406) in both groups were
also randomized to aspirin or placebo.386
It is unclear how
many in each group were concurrently taking aspirin, but
analyses controlled for aspirin status. The results from the
aspirin subset were not graded for level of evidence.
However, in the aspirin-only analysis, aspirin did not
improve primary or secondary outcomes. Also, in a subsequent
independent publication, fish oil was found to be
associated with reduced rates of AV access in-
terventions.345
Finally, the far-infrared therapy studies
demonstrated significantly improved primary AVF patency
rates compared with no treatment. Although several of
these pharmacologic and technologic therapies have
shown benefit, the Work Group recommends an individualized
approach toward implementing these therapies
because the sample size was small in several of these
studies.
Arteriovenous Grafts. There were 2 major studies
evaluating pharmacologic therapies in AVG, fish oil388
and
dipyridamole/aspirin.96
The fish oil study showed
improved primary but not secondary AVG patency.
Dipyridamole/aspirin also showed improved primary
patency. Clinical practice implementation based on the
results of these studies needs to be individualized.
Although in combined studies fish oil did not show significant
benefit for AVF patency, it was associated with
reduced frequency (rate) of thrombosis and interventions,
and it prolonged the time to thrombosis. Overall, fish oil
has low-risk profile; risks and benefits can be considered
within the patient’s ESKD Life-Plan.
On the other hand, although dipyridamole/aspirin
showed a significant statistical benefit to reduce loss of
primary patency, the benefit of the therapy realistically was
very modest: primary unassisted patency in the dipyridamole/aspirin
group was 28% versus 23% in the placebo
group (ie, taking dipyridamole/aspirin delayed loss of
primary patency by 6 weeks).96
However, the risks of
potential complications of frailty, falls, and bleeding must
be individualized before considering use of this therapy.
Although not reviewed by the ERTfor these guidelines, the
efficacy of the combination of aspirin and clopidogrel in the
prevention of graft thrombosis was evaluated in a Veterans
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S90 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Affairs Cooperative study.391
The study was a randomized,
double-blind trial conducted at 30 hemodialysis units at
Veterans Affairs medical centers. Participants undergoing
hemodialysis with an AVG were randomized to receive either
double placebos or aspirin (325 mg) and clopidogrel (75
mg) daily. Participants were to be monitored while receiving
study medications for a minimum of 2 years. The study was
stopped after randomization of 200 participants by the Data
Safety and Monitoring Board because of a significantly
increased risk of bleeding among the participants receiving
aspirin and clopidogrel therapy. The cumulative incidence of
bleeding events was significantly greater for those participants
compared with participants receiving placebo (HR,
1.98; 95% CI, 1.19-3.28; P = 0.007).391
Among the vascular
access outcomes data reported, there was no significant
benefit of active treatment in the prevention of thrombosis
(HR, 0.81; 95% CI, 0.47-1.40; P = 0.45).391
Similar
increased major bleeding risks were noted in a wellconducted
double-blind RCT of low-dose warfarin (target
international normalized ratio [INR], 1.4-1.9) versus placebo
to reduce HD graft thrombosis.392
Although these studies did now
show benefit of an antiplatelet agent or anticoagulant to reduce AVG
thrombosis, they more importantly highlight theneedfor assessingthe risks for
potential complications of using antiplatelet or anticoagulant agents in an
elderly and frail population, where the benefit of the therapy may only be
modest or absent.
Special Discussions
Overall, there were very few studies that evaluated therapies
to prevent AVF and AVG dysfunction that were of
high-quality evidence. Even in those studies of high
quality, careful consideration should be made before using
additional therapies based on statistically significant results
in the absence of important clinically meaningful
differences.
Implementation Considerations
 Some of these therapies, such as far-infrared therapy,
may not be widely available outside of Asia.
 Antiplatelet and anticoagulant agents may increase risk
of bleeding, and their use needs to be carefully
considered in the elderly population and those patients
with high bleeding risks.
Monitoring and Evaluation
 Because a number of these therapies have been performed
in smaller studies and often nonrandomized
studies, adverse events need to be closely monitored and
evaluated.
 A number of these agents have adverse events such as
bleeding, so these complications must be closely
monitored and evaluated.
Future Research
 Far-infrared therapies for AVF and AVG dysfunction in
populations outside of Taiwan
 The FISH study did not reach its enrollment target;
additional studies of omega-3 fatty acids, including
those with different formulations and/or different
doses, may provide insight to potential benefits for AV
access outcomes.
Guideline 15. AV Access Flow
Dysfunction—Confirmation and Treatment
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Radiographic Confirmation of
Clinically Significant AV Access Lesion
15.1 KDOQI considers it reasonable that when clinical
monitoring suspects clinically significant AV access
lesion (eg, stenosis), further timely and
confirmatory evaluation should proceed,
including imaging of the dialysis access circuit.
(Expert Opinion)
Notes:
 A clinically significant lesion is one that contributes to clinical
signs and symptoms (see AV Access Monitoring, Table 13.2)
without other cause (with or without a change in surveillance
measurements, such as change in blood flow [Qa] or venous
pressures).
 Dialysis access circuit is defined as the continuum from the
heart and the arterial inflow through the AV access to the
venous outflow back to the heart.
 The timeframe, choice, and extent of imaging studies for
further evaluation are dependent on local resources and the
severity of findings on clinical monitoring; a timeframe of less
than 2 weeks was deemed reasonable by the KDOQI Work
Group.
15.2 KDOQI considers it reasonable to use the smallest
volume of iodinated contrast or non-iodinated
contrast agents (eg, CO2 gas) by operators
knowledgeable in their uses, contraindications,
and risks to obtain the best possible image in all
patients with CKD to preserve residual kidney
function. (Expert Opinion)
15.3 KDOQI considers it reasonable that when further
confirmatory imaging studies reveal a culprit
lesion responsible for clinical signs and symptoms,
the clinically significant lesion is promptly
treated. (Expert Opinion)
Note: A clinically significant lesion is one that contributes to clinical signs
and symptoms (see AV access Monitoring, Table 13.2) without
other cause (with or without a change in surveillance measurements,
such as change in blood flow [Qa] or venous pressures).
Guideline 15. AV Access Flow Dysfunction—Confirmation and Treatment
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S91
Statement: General Treatment of Clinically
Significant Stenosis or Thrombosed AV Access
15.4 KDOQI considers it reasonable to use a careful
individualized approach to the treatment of
failing or thrombosed AVF and AVG (surgical or
endovascular), based on the operators best clinical
judgment and expertise considering the patient’s
ESKD Life-Plan. (Expert Opinion)
Note: Consider both the patient’s individual circumstances and the operator’s
clinical experience and expertise (ie, reasonable capabilities and limitations);
preferably discussed and agreed on by the team managing the
patient’s vascular access, including but not limited to the patient
and one or more of the following: nephrologist, interventionalist,
surgeon, vascular access coordinator, cannulators (nurse or
technician).
Statements: Treatment of Clinically Significant AV
Access Stenosis
Angioplasty
15.5 KDOQI considers it reasonable to use balloon
angioplasty (with high pressure as needed) as
primary treatment of AVF and AVG stenotic lesions
that are both clinically and angiographically
significant. (Expert Opinion)
Note: Angiographically present stenosis without accompanying clinical
signs and symptoms is inadequate to treat/intervene upon.
15.6 There is inadequate evidence for KDOQI to make
a recommendation regarding the use of specialized
balloons (drug-coated or cutting) versus
standard high-pressure balloons in the primary
treatment of AVF and AVG stenosis.
15.7 There is inadequate evidence for KDOQI to make
a recommendation regarding the optimal duration
of balloon inflation time during angioplasty
to improve intervention primary patency in the
treatment of AVF or AVG stenosis.
15.8 KDOQI considers it reasonable that a careful
patient-individualized approach to the choice of
balloon type for angioplasty of clinically significant
AVF and AVG stenosis be based on the operator’s
best clinical judgment and expertise.
(Expert Opinion)
Stents
15.9 KDOQI suggests the appropriate use of selfexpanding
stent-grafts in preference to angioplasty
alone to treat clinically significant graftvein
anastomotic stenosis in AVG when the
goal is overall better 6-month postintervention
outcomes after carefully considering the patient’s
ESKD Life-Plan. (Conditional Recommendation,
Moderate Quality of Evidence)
Note: Appropriate use avoids cannulation segments.
Note: Overall better 6-month outcomes refer to reduced recurrent
AVG restenosis ± improved patency.
15.10 KDOQI considers it reasonable to first consider
the consequences of placement of a stent-graft
on future AV access options according to the
patient’s ESKD Life-Plan, with consultation with
the vascular access team if necessary, prior to its
placement. (Expert Opinion)
15.11 KDOQI suggests that the use of an appropriately
placed stent-graft is preferred to angioplasty
alone for the treatment of in-stent restenosis in
AVG and AVF for overall better 6-month postintervention
outcomes. (Conditional Recommendation,
Moderate Quality of Evidence)
Note: Appropriate use avoids cannulation segments.
Note: Overall better 6-month outcomes refer to reduced recurrent
AVG and AVF restenosis ± improved patency.
15.12 KDOQI considers it reasonable to avoid the use of
bare metal stents for the treatment of clinically
and/or angiographically significant AVG and AVF
stenotic lesions. (Expert Opinion)
Rationale/Background
Maintaining effective functioning AV access (AVF and
AVG) is an ongoing challenge that frequently requires
remedial treatment for problematic AV accesses (see
Table 13.2, Clinical Indicators (Signs and Symptoms)
Suggesting Underlying Clinically Significant Lesions During
Access Monitoring), especially if AV access thrombosis
occurs as a terminal event. Several of these conditions are
addressed in separate sections of the Guidelines
(Guidelines 16-19). The generic approach to these various
failure modes includes appropriate monitoring and imaging
to identify the underlying cause and then definitive
treatment of the clinically significant culprit lesion. Various
endovascular approaches have largely replaced the open,
surgical approach and should be used as the first line of
treatment, with the surgical approach reserved for endovascular
failures, lesions not amenable to endovascular
treatment, and those select lesions in which the surgical
approach is deemed far more durable.
Stenosis is the most common complication after AV
access creation.393
Venous stenosis is often the result of
neointimal hyperplasia394
and leads to several serious
sequelae in both AVF and AVG. Stenosis causes AVF nonmaturation
with the attendant reliance on CVCs. AVF
maturation failure has been reported in observational
studies to range from 20% to 60%.77,233,234
Furthermore,
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S92 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
a multicenter RCT in the United States reported that up to
60% of AVFs failed to mature successfully for dialysis
use.31
Stenosis also causes dysfunction in mature AVFs
resulting in inadequate HD clearance, thrombosis, and
eventual abandonment. AVGs are also susceptible to stenosis
developing at the graft-vein junction, leading to
thrombosis in 80% of AVGs.235,236,238,239,395
The previous
2006 KDOQI guideline maintained that PTA is the first-line
treatment for stenosis in the access circuit.13
Although this
generally remains the case in the modern era of vascular
access, several important clinical trials and device innovations
are considered that may alter the indications for
angioplasty and the types of balloons and stents for treatment
of stenosis. The current recommendations update
those from the previous Guidelines.
Detailed Justification
Maintaining vascular access function required to provide
adequate goal-directed dialysis is an ongoing challenge for
all access types and configurations; all have a limited life
expectancy. The complication and remediation rates (eg,
infection, sepsis, thrombectomy) vary by the dialysis access
type (CVC: 0.7 and 2.1 episodes/year; AVF: 0.14 and 0.44
episodes/year; AVG: 0.25 and 0.77, episodes/year,
respectively)396,397
and are detailed in various sections of
this Guideline. In addition to the significant morbidity
associated with dialysis access complications,398
procedures
to confirm and manage AV access flow–related problems
have been deemed the most burdensome to patients, often
leading to patient dissatisfaction.345
It is the responsibility of
the treating team to ensure appropriate detection of failing
AV access and judicious use of invasive procedures in the
diagnosis and treatment of culprit lesions. To provide
greater clarity, the Work Group has replaced the term AV
access dysfunction with 3 more specific terms describing AV
access complications: (1) thrombotic-flow related complications
or dysfunction; (2) nonthrombotic-flow–related
complications or dysfunction, and (3) infection-related
complications or dysfunction (see Glossary). It is incumbent
on all health care providers who care for HD patients to
be familiar with the various vascular access complications
and failure modes. It is critical to emphasize that reducing
complications and vascular access failure begins before a
vascular access is created, with proper patient selection and
an appropriate vascular access plan (vascular access creation
plan) that considers the entire life cycle of the vascular access
(vascular access contingency and succession plans) with
the appropriate monitoring and care within the dialysis unit.
Detection and Diagnosis of Clinically Significant
Stenosis and Related Complications
A clinically significant stenosis within the HD access circuit
is associated with patient signs and symptoms and can lead
to abnormal dialysis indicators (Table 13.2). The HD
vascular access circuit should be viewed as a continuum
from the left side of the heart, through the outflow arterial
inflow to the anastomosis and back again, through the
peripheral veins (or graft) to the central veins, and ultimately
to the right side of the heart. AV accesses can
develop lesions, especially stenosis, at any point within this
circuit. AVGs typically develop stenoses at the graft-venous
anastomoses, whereas AVFs typically develop stenoses in
the juxta-anastomotic region and the swing segment for
brachial-basilic AVF and the cephalic arch for brachialcephalic
AVF.399-402
As noted in Guideline 15, the indication
for further evaluation and definitive treatment requires
the presence of a clinically symptomatic, significant
lesion and not simply the presence of a lesion (ie,
asymptomatic stenosis).403,404
Once routine monitoring reveals a clinically important
vascular access problem (Guideline 13), the diagnostic
approach is contingent on the clinical suspicion of the
underlying lesion (ie, arterial inflow, anastomosis, venous
outflow). Duplex ultrasound is effective for examining the
AV access from the arterial anastomosis throughout the
peripheral venous section (or graft) and may ascertain
causes of thrombotic flow–related complications/
dysfunction such as neointimal hyperplasia (NH), thickened
venous valves, and competing accessory veins.
However, it is ineffective for interrogating the central
venous outflow, given the limitations of ultrasound and
the bony thoracic cavity. Arterial duplex ultrasound can be
helpful to image the peripheral arteries but is again limited
for assessing the great vessels in the chest. Catheter-based
venography and arteriography are invasive procedures
but can definitively image the AV access from the anastomosis
to the heart (venography) or the whole AV access
circuit (arteriography) while serving as a platform for
therapeutic interventions. CT arteriography and venography
are alternative diagnostic studies for most peripheral
vascular interventions but may have practical limita-
tions.405
These diagnostic procedures may use iodinated
contrast that is potentially nephrotoxic and should be used
judiciously in patients with CKD/ESKD and residual kidney
function—on or off dialysis. Indeed, the choice of contrast
needs to be factored into the imaging algorithm. Carbon
dioxide can be used as an alternative non-nephrotoxic
contrast agent for catheter-based procedures in select
cases, although the quality of the imaging may not be
sufficient to guide interventions, and caution should be
exercised to avoid intra-arterial injection in the upper extremity
due to the potential of the gas to pass into the
cerebral arterial circulation and cause neurologic events.406
Intravascular ultrasound can also be helpful in patients
with severe contrast allergies.407
MRI is also an alternative
to CT arteriography, although the published experience is
limited, and the use of the MRI contrast agent gadolinium
is relatively contraindicated due to the risk of nephrogenic
fibrosis.405,408
Appropriate imaging of the dialysis circuit should
identify the culprit lesion and suggest definitive treatment
strategies. Venous stenoses throughout the peripheral vein
for AVFs and at the venous anastomoses for AVGs are
Guideline 15. AV Access Flow Dysfunction—Confirmation and Treatment
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S93
typically treated with endovascular therapies given their
less invasive nature. Notably, these stenoses are typically
dense, fibrous lesions from intimal hyperplasia and are
distinctly different from arterial atherosclerotic lesions.
Anastomotic lesions can likewise be treated with an
endovascular-first approach, although they may not be as
amenable to angioplasty, and, thus, more suited for open
repair. The choice of treatment for atherosclerotic arterial
inflow lesions should be based on their natural history,
independent of the fact that they involved vessels
providing inflow to the AV access. Accordingly, subclavian
orifical lesions are typically treated with a combination of
balloon angioplasty and intraluminal stenting with the
more peripheral lesions (ie, axillary, brachial, radial, ulnar)
treated by endovascular methods or open surgical
repair using bypass or patch angioplasty.
Angioplasty for Treatment of Clinically Significant
Stenoses
High-Pressure Balloon Angioplasty. Venous stenosis
from NH is characterized by a concentric thickening and
a lumen diameter reduction caused by myointimal cell
proliferation.409
Although there are several putative
mechanisms that may promote NH, including an inflammatory
reaction secondary to the AVF creation surgery,
hemodynamic shear stress, trauma related to needle
punctures, and possibly as a direct result of uremia,410
a
durable solution to NH-induced stenosis remains elusive.
Re-stenosis at the initial lesion or elsewhere in the previously
treated dialysis circuit occurs up to 60% of the
time at 6 months.411
In addition, the usual percutaneous
angioplasty (PTA) solution to AV access stenosis is the
very mechanism by which NH is induced in the porcine
model and vessels progressively injured in HD pa-
tients.412
Due to these fundamental limitations in the
efficacy of standard PTA, several innovations were
evaluated in this Guidelines. Aside from the special circumstances
described herein, standard high-pressure
balloon angioplasty remains the treatment of choice for
the majority of anatomic and clinically significant AV
access stenotic lesions. A clinically significant AV access
stenotic lesion is one that is accompanied by clinical signs
and symptoms (refer to section Guideline 13 and
Tables 13.1 and 13.2) and shows >50% narrowing
relative to adjacent normal vein diameter by angiography
or ultrasound.
Paclitaxel-Coated Balloon Angioplasty in AVF. An
RCT (N = 40) evaluated treatment with paclitaxel drugcoated
balloons (PCBs) (Supplement 3, Table S178)
compared with high-pressure balloons for treatment of
single stenotic lesions in AVFs.413,414
Patients were followed
to 1 year with clinical assessments every 2 months.
Both groups received oral aspirin 100 mg daily after angioplasty.
Primary patency at 200 days was not significantly
different with PCB versus high-pressure balloons
(RR, 2.25; 95% CI, 0.83-6.13). However, treatment lesion
re-stenosis-free survival was significantly superior in the
PCB group compared with the high-pressure balloon
group (PCB, 308 days vs balloon, 161 days; HR, 0.47;
95% CI, 0.23-0.96; P = 0.03), as was access circuit primary
patency (ACPP) (median days): 270 versus 161 days
(HR, 0.48; 95% CI, 0.23-0.97). Thrombosis at 1 year did
not differ (RR, 2.0; 95% CI, 0.2-20.3).414
Another small
RCT (N = 10) compared PCB with plain balloon versus
plain balloon alone for treatment of stenotic AVF where
each access circuit had 2 lesions, 1 treated with PCB and
the other without. Each patient acted as his/her own
control and was followed for 1 year.415
A high-pressure
balloon was used if a plain balloon did not adequately
treat the target lesion. Primary patency at 1 year was not
significantly different with PCB and plain balloons versus
plain balloon alone (20% vs 0%; P = 0.47). AngioplastyTable
15.1. Outcomes of Paclitaxel-Coated Balloon Angioplasty in AVGs and AVFs
Outcome Paclitaxel-coated PTA Plain balloon PTA RR, HR, or P value
Primary patency at 1 year (all AV accesses) No difference No difference RR, 7.0
95% CI, 0.95-51.8
Median primary patency (all AV accesses), years 0.64 0.36 P = 0.0007
adjusted HR, 0.23
95% CI, 0.10-0.50
Primary patency at 1 year (AVG), % 38 0 P = 0.003
Median primary patency (AVG), years 0.62 0.21 P = 0.002
unadjusted HR, 0.22
95% CI, 0.08-0.57
Primary patency at 1 year (AVF), % 29 14 P = 0.26
Median primary patency (AVF), years 0.78 0.43 P = 0.15
unadjusted HR, 0.42
95% CI, 0.13-1.44
Abbreviations: AV, arteriovenous; AVF, arteriovenous fistula; AVG, arteriovenous graft; CI, confidence interval; HR, hazard ratio; PTA, primary balloon
angioplasty; RR, relative risk.
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S94 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
free days were significantly greater with PCB and plain
balloons versus plain balloon alone (251 vs 103 days; P <
0.01).
Paclitaxel-Coated Balloon Angioplasty in AVG. One
RCT (N = 40) compared paclitaxel-coated balloon versus
plain balloon for PTA in stenotic AV access (14 AVF [n =
14] and 26 AVG) at 1 year413
(Table 15.1).
Thrombosis was not significantly different with PCB
versus plain balloon (RR, 1.0; 95% CI, 0.l6-6.42).
Angiographic restenosis was significantly lower with PCB
versus plain balloon (RR, 0.68; 95% CI, 0.49-0.96), as was
the need for repeat angioplasty procedures (RR, 0.63; 95%
CI, 0.44-0.92).
A recent meta-analysis found that paclitaxel-coated stents
and balloons used in patients with peripheral arterial disease
for claudication was associated with an increased 5-year
mortality. A causative factor, if any, has not been ascertained—it
is unclear if this finding is relevant to the HD patient
population and vascular access.416
Cutting Balloon Angioplasty. Two RCTs compared
cutting balloon angioplasty with high-pressure balloon
angioplasty for the treatment of stenosis in AVF.417,418
One Canadian trial (N = 48; 39 analyzed), included participants
with de novo stenoses. Another Singapore-based
study (N = 77; 71 analyzed) included participants with
stenoses for whom conventional pressure balloon angioplasty
had failed who were randomized to cutting balloon
PTA versus high-pressure balloon PTA. Average age of the
AVF was approximately 15 months in the Canadian trial
and 22 months in the Singapore trial.418
Clinical treatment
success, defined as the ability to perform at least 1 successful
dialysis procedure using the AVF after angioplasty,
was 96% and did not differ between groups (RR, 1.00;
95% CI, 0.95-1.05). Technical treatment success, defined
as <30% residual stenosis, did not differ at 95% and 98%
in the cutting and high-pressure arms, respectively (RR,
0.98; 95% CI, 0.91-1.05]. Overall, 6-month primary
patency did not differ between groups.
Study details and evidence quality are provided in
Supplement 3, Table S167.
Angioplasty Balloon Inflation Time. One RCT (N =
48) compared a 1-minute inflation time with a 3-minute
inflation time during PTA of AV access stenosis.419
Most
were AVF (88%), with an average age of 692 days. There
were 40 stenoses in the 27 participants allocated to the 1minute
group and 36 stenoses in the 21 participants
allocated to the 3-minute group. Results were reported up
to 6 months. Treatment success, defined as a reduction of
stenosis to less than 30% of the luminal diameter or a
reduction of the mean gradient to less than 10 mm Hg in
peripheral or to less than 5 mm Hg in central lesions, did
not differ statistically between groups (75% in the 1minute
group vs 89% in the 3-minute group ; P =
0.12). Primary patency did not differ between groups at
any of the postintervention intervals of 1, 3, or 6 months.
Kaplan-Meier estimates of 6-month patency were 63% and
47% for the 1- and 3-minute duration groups, respectively.
An observational trial (N = 75) analyzed prospectively
collected data from a vascular access database of
stenotic AVGs and AVFs with 223 interventions (178 with
30-second inflations and 45 with 1-minute inflations).420
Demographics and baseline characteristics were similar
across groups. Immediate technical success and patency in
the first 3 months did not differ (HR, 0.86; 95% CI, 0.34-
2.20). After 3 months, however, a 1-minute inflation time
was associated with greater incidence of AV access failure
(adjusted HR, 1.74; 95% CI, 1.09-2.79).
Stents for Treatment of Clinically Significant
Stenoses
See Table 15.2 for indications for stent use in AV access.
Stents-grafts in AVG. Two RCTs evaluated stent grafts
for treating AVG stenosis: Haskal et al421
and Vesely
et al422
compared treatments for AVG venous anastomotic
stenosis using angioplasty with placement of stent-grafts
versus angioplasty alone. Haskal et al conducted a
Table 15.2. Indications for Stent-Graft Use in AV Access
Please note that the indications for stent graft use is for 6 month outcomes only.
The numbers of patients at risk in the individual studies were too small for the ERT to determine impact on 12- and 24-month outcomes.
Studies have not sufficiently or consistently shown stent graft use to improve AV access thrombosis rates or cumulative AV access survival beyond 6
months.
The indications below are relevant to AV accesses in the absence of central vein occlusion. Before the use of a stent-graft, clinicians should first
consider the impact of its placement on (1) the current access’s ability to be cannulated without harm and (2) the patient’s ESKD Life-Plan and
subsequent vascular access creation and use.
 Recurrent clinically significant graft-vein anastomotic stenosis in AVG
 Recurrent graft-vein anastomotic thrombosis in AVG
 In-stent re-stenosis in AVF and AVG
 Treatment of ruptured venous stenotic segment of AVF and AVG
 Treatment of highly select AV access aneurysm/pseudoaneurysm (see AV access aneurysms section)
Note: Overall better 6-month outcomes refer to reduced recurrent AVG restenosis ± patency (target lesion and AV access circuit). To achieve
consensus in the Guidelines, Table 15.2 reflects the Work Group’s very considered decision to incorporate and balance the available evidence with
expert opinion (eg, Guideline Statements 15.9-15.11), considering clinical practice and the long-term needs of patients, with the limited follow-up time
and numbers from the available evidence. This highlights the need for further rigorous study of stent-graft use in AV accesses, which considers the
findings on clinical monitoring and surveillance that lead to the indications for investigation and treatment, and the need for longer follow-up, including
the impact of treatments on future AV access creation and use.
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S95
multicenter RCT (N = 190) that compared angioplasty
with placement of a stent-graft (self-expanding nitinol
polytetrafluoroethylene stent [Flair Endovascular Stent
Graft, Bard Peripheral Vascular]) to high-pressure angioplasty
alone to treat AVG venous anastomotic stenosis.
Participants were followed for 6 months. Treatment
groups were similar at baseline, except for more anastomoses
at the axillary vein among the angioplasty-alone
group. Thrombosed accesses were excluded, and a
mandatory 6-month angiogram was performed. Vesely
et al conducted a multicenter RCT (N = 293) that
compared angioplasty with placement of a stent-graft (selfexpanding
polytetrafluoroethylene stent with a heparin
bioactive surface and an external nitinol structure (Viabahn
Endoprosthesis With Heparin Bioactive Surface, WL Gore)
to angioplasty alone to treat AVG venous anastomotic
stenosis.422
Participants were followed for 24 months.
Treatment groups were similar at baseline, except for more
Hispanic/Latino participants among the angioplasty-alone
group. Thrombosed AVGs were included, and follow-up
was conducted per individual site standard of practice
with no mandatory angiogram. Outcomes were reported
for both intent-to-treat and per-protocol populations; only
the intent-to-treat outcomes were extracted and analyzed
by the ERT. Because Vesely et al also reported primary
patency for patients with stenosis versus thrombosis
separately, the outcomes for patients with stenosis were
pooled with outcomes from Haskal et al and analyzed.
In a pooled analysis, treatment area primary patency
(TAPP) by angioplasty with stent graft versus angioplasty
alone at 6 months was significantly higher among stenotic
lesions (RR, 1.71; 95% CI, 1.11-2.64) and among all lesions
(stenotic and thrombotic) (RR, 1.50; 95% CI, 1.14-
1.97) in Vesely et al.422
However, in the shorter term,
TAPP was not significantly different for angioplasty with
stent graft versus angioplasty alone among stenotic lesions
at 2 months (RR, 1.04; 95% CI, 0.90-1.21). ACPP by
angioplasty with stent graft versus angioplasty alone at 6
months was significantly higher in a pooled analysis
among stenotic lesions (RR, 1.58; 95% CI, 1.30-2.20) and
in the study by Vesely et al, among all lesions (stenotic and
thrombotic) (RR, 1.46; 95% CI, 1.06-2.01). However, in
the Haskal et al study, ACPP was not significantly different
for angioplasty with stent graft versus angioplasty alone
among stenotic lesions at 2 months (RR, 1.03; 95% CI,
0.88-1.19).
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S168-S177.
Several intermediate outcomes evaluated showed that
angioplasty with stent graft, compared with angioplasty
alone, had (1) higher freedom from subsequent intervention
(32% angioplasty with stent graft vs 16% angioplasty
alone; P = 0.03),421
(2) lower risk of restenosis (RR,
0.52; 95% CI, 0.40-0.68), (3) longer median time to loss
of TAPP among all lesions (2,013 days for angioplasty with
stent vs 108 days for angioplasty alone),423
and 4) longer
median time to loss of ACPP among all lesions (126 days
for angioplasty with stent s 91 days for angioplasty alone).
Tests for significance were not reported and were not
calculable in time-to-event analyses.
Haskal et al421
and Vesely et al 422
did not report other
intermediate health outcomes. Harms associated with
treatment, including infection (RR, 2.84; 95% CI,
0.59-13.72), pseudoaneurysm (RR, 2.37; 95% CI, 0.47-
11.90), and vessel rupture (RR, 2.84; 95% CI, 0.30-
26.82), were not significantly different for angioplasty
with stent graft versus angioplasty alone in Haskal et al.
Adverse events within 30 days, whether major (risk difference,
-0.01; 95% CI, -0.03 to 0.005; RR, undefined) or
minor (RR, 2.04; 95% CI, 0.38-10.97) were not significantly
different for angioplasty with stent grafts versus
angioplasty alone in Vesely et al.
The Work Group discussed these studies and their implications
at great length. Concerns raised included the fact
that the Haskal et al study421
used protocol angiograms to
detect lesions, which may not have been clinically significant;
thus, the generalizability and relevance to clinical
practice was questioned. There was also no difference in
clinically important thrombosis. After the literature review
and data extraction by the ERT, another study was published
(RENOVA, by Haskal et al), which was similar in
design as the prior Haskal study but with longer follow-
up.424
The Work Group reviewed and considered this
study as well. All studies that reported 12- and 24-month
outcomes had low numbers of remaining patients at risk,
leaving uncertainty in interpretation (for example, in
Haskal et al, at 12 months, the total number of evaluable
patients at risk was 9, and at 24 months it was 0, for
ACPP).
The Work Group statements reflect the consideration of
the outcomes of all 4 published studies and their clinical
interpretation, application, and relevance in light of the
Work Group concerns.
Stent-grafts in AVF. Two RCTs evaluated stent grafts
for treating AVF stenosis.425,426
Shemesh et al425
and Rajan
et al426
compared treatments for cephalic arch stenosis;
Shemesh et al compared angioplasty with a stent graft
versus angioplasty with a bare-metal stent, whereas Rajan
et al compared angioplasty with a stent graft versus angioplasty
alone. The ERT did not extract data for analysis
from the Rajan et al study, due to the study’s high risk of
bias.
Shemesh et al (N = 25) compared the 2 groups for
treating recurrent cephalic arch stenosis within 3 months
of a previous successful PTA of a brachiocephalic AVF,
with up to 15 months follow-up (mean, 13.7 months).425
The stent graft was a self-expanding nitinol stent covered
by expanded polytetrafluoroethylene (Fluency Plus, Bard
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S96 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Peripheral Vascular, Angiomed GmbH & Co Medizintechnik
KG). The bare-metal stent was a self-expanding
nitinol stent (Luminex, Bard Peripheral Vascular,
Angiomed GmbH & Co Medizintechnik KG). Stent grafts,
compared with bare-metal stents showed (1) higher primary
patency (HR, 4.09; 95% CI, 1.9-20.3; P = 0.002)
and (2) no difference in secondary patency (P = 0.29 by
log-rank test) at 1 year.
Interventions for re-stenosis were significantly fewer
with a stent-graft versus a bare-metal stent during total
follow-up (RR, 0.46; 95% CI, 0.22-0.96), as were overall
interventions per patient-year (RR, 0.47; 95% CI, 0.36-
0.61). Re-stenosis was defined as >50% stenosis at 3
months as determined by angiography. Re-stenosis at 3
months was significantly lower with a stent-graft (RR,
0.26; 95% CI, 0.07-0.97). Of note, no sample size
determination was made, and methodology for randomization
was not provided. The Work Group had discussions
about these studies and shared concerns about making
statements based on the small numbers in these studies
and, therefore, refrained from doing so.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S168-S177.
Stent-Graft for In-Stent Restenosis. The next study
was discussed by the Work Group, but it did not meet
entry criteria for retrieval and review by ERT due to its
publication date. A multicenter RCT (N = 275) by Falk
et al427
evaluated the efficacy of stent-graft versus angioplasty
alone for the treatment of in-stent re-stenotic lesions
in the venous outflow of the AV access circuit of AVGs and
AVFs.427
Primary endpoints were ACPP at 6 months and
safety through 30 days; secondary endpoints were evaluated
through 24 months. ACPP at 6 months was significantly
higher in the stent-graft group (18.6%) versus the
angioplasty group (4.5%; P < 0.001), and freedom from
safety events (30 days) was comparable (stent graft,
96.9%; angioplasty, 96.4%; P = 0.003 for noninferiority).
TAPP was superior for the stent-graft group (66.4%)
versus the angioplasty group (12.3%) at 6 months (P <
0.001). ACPP and TAPP for the stent-graft group demonstrated
similar outcomes in central and peripheral vein
subgroups (P < 0.001). Of note, overall or secondary access
patency was not assessed.
Thrombolysis—Endovascular and Surgical
Despite efforts at prevention of thrombosis, either via
pharmacologic prophylaxis or angioplasty of stenosis, access
thrombosis frequently occurs. Percutaneous thrombectomy
remains an essential endovascular procedure,
with a variety of approaches to this procedure. The method
chosen depends on operator experience, available resources,
and patient factors. Although immediate success
to provide at least 1 effective dialysis session after the
procedure can be achieved in 80% to 95% of thrombosed
AVGs and AVFs,428
long-term patency after thrombectomy
remains elusive, with reported rates of 25% to 50% at 6
months and 10% to 20% at 1 year.429
For AVGs, a metaanalysis
of 8 RCTs compared surgical thrombectomy to
endovascular therapy for thrombosed AVGs and found
outcomes to be comparable.430
With regard to AVFs, only
observational studies on the treatment of thrombosed AVFs
were identified that also showed similar primary outcomes
of surgical and endovascular interventions.431
Surgery
Open surgical repair is generally reserved for recurrent
lesions, those not amenable to endovascular treatment, and
those for which the outcomes associated with the endovascular
approach are poor.432,433
There are a variety of
open surgical techniques for these peripheral venous lesions,
including interposition grafting and patch angioplasty,
with the choice typically dictated by the extent of
the lesion. Notably, Romann et al434
reported that failure
of balloon angioplasty for AVF stenoses was correlated
with the length of the lesion, with those >2 cm having a
higher failure rate, suggesting that these may be better
treated with an open approach. Brachiocephalic AVFs and
brachiobasilic AVFs frequently fail due to development of
stenoses at the cephalic arch and “swing segment”
(proximal hinge for the mobilized basilic vein). Both of
these lesions are amenable to endovascular treatment, but
the surgical alternative may be more durable and remains
an option for recurrent lesions after failed endovascular
treatments. Two series have reported favorable surgical
results for the cephalic arch stenoses,435,436
although a
systematic review failed to identify a superior approach
among the open and endovascular options.437
Special Discussions
 Should stents and their variations be used, it is important
to avoid placing them at AV access cannulation
segments to preserve AV access functionality and use.
 Overall, there were very few studies that evaluated
therapies to prevent AVF and AVG dysfunction that were
of high-quality evidence.
 See commentary in Detailed Justification section for
Work Group discussion of stent-graft use.
Implementation Considerations
 Close follow-up and documentation of the effects of
stent-graft use on short- and long-term outcomes for
the currently affected and future AV accesses
Monitoring and Evaluation
 Because a number of these therapies have been performed
in smaller and often nonrandomized studies,
adverse events need to be closely monitored and
evaluated.
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S97
Future Research
 Study the patient and AV access outcomes and impact of
(1) ultrasound-guided angioplasty and (2) intravascular
ultrasound-guided angioplasty, to limit contrast exposure
in CKD/ESKD patients with residual kidney function
and urine output
 Stent-grafts versus bare-metal stents for treatment of
central vein stenosis requires more RCT evaluation, with
larger numbers, rigorous conduct, and analysis.
 More RCT evaluation of stent-grafts for vascular access
management (primary or secondary) with clinical-based
(rather than angiogram) outcomes are urgently required.
 Study is needed in AVFs for multiple modalities of
treatment (eg, stent-grafts, drug-eluting balloons, etc).
 Comparative methods of AV access thrombolysis (eg,
surgical vs endovascular) with a variety of short- and
longer-term AVF and AVG outcomes
 Increasing evidence in the following areas:
 The use of specialized balloons (drug-coated or cutting)
versus standard high-pressure balloons in the
primary treatment of AVF and AVG stenosis
 The optimal duration of balloon inflation time during
angioplasty to improve intervention primary patency
in the treatment of AVF or AVG stenosis
 The secondary use of drug-coated balloons after
successful angioplasty with high-pressure balloons
for treatment of stenosis in AVF and AVG
 Impact of timing of recurrence of stenosis on choice of
treatment modality
 Use of stent grafts in locations other than graft-vein
anastomosis or cephalic arch in brachiocephalic AVFs
 Optimal treatment of in-stent stenosis that occurs in
stent-grafts
 Study outcomes with surgically corrected occluded AV
accesses that are followed by a completion angiogram/
imaging ± further corrective procedure. How does this
strategy compare with historical surgical correction
without completion imaging or with endovascular
management?
 The optimal timing of angioplasty/thrombolysis or
thrombectomy in thrombosed AVF and AVG
 Studies to determine the best measurement that defines
a successful procedure outcome: for example, should it
be a percent relative improvement in lumen size or an
absolute lumen diameter or other measurement? When
should it be measured after the treatment (eg, PTA)
(during the procedure or after?)
Statements: Treatment of Thrombosed AV Access
15.13 KDOQI considers it reasonable that management
of each episode of AV access thrombosis is at the
operator’s/clinician’s best judgement and
discretion, and involves the consideration of the
patient’s dialysis access Succession Plan that is
consistent with the ESKD Life-Plan, given the
compromised AV access patency after either
endovascular or surgical treatment. (Expert Opinion)
Note: Operators/clinician’s discretion carefully considers both the
patient’s individual circumstances and the operator’s/clinician’s own
clinical experience and expertise (ie, reasonable capabilities and limitations).
The Succession Plan is a critical component of the P-L-A-N (see
Monitoring and Evaluation discussion in Guideline 1).
15.14 KDOQI considers it reasonable to surgically treat a
failing AV access in the following circumstances:
(1) endovascular treatment failures, (2) clinically
significant lesions not amenable to endovascular
treatment, and (3) situations in which the surgical
outcomes are deemed markedly better. (Expert
Opinion)
Note: Situations when surgical outcomes are anticipated to be better
than alternative options should be first discussed and agreed upon by the team
managing the patient’s vascular access, including but not limited to
the patient and one or more of the following: nephrologist, interventionalist,
surgeon, vascular access coordinator, and cannulation expert,
if possible.
Rationale/Background
Fully occlusive thrombosis represents the terminal event for
the failing AV access and accounts for 65% to 85% of all AV
access abandonments.438
Although the contributory cause of
the terminal thrombotic event is usually obvious (eg, low flow
related to venous outflow stenosis in AVG), patients can present
with de novo thrombosis without any clear failure
mechanism.439
The clinical priorities include providing
necessary effective dialysis, clearing the intraluminal
thrombus, and definitively treating the underlying cause of the
failure.
The diagnosis of a thrombosed AV access is often
obvious on physical examination but can be confirmed
with duplex ultrasound. Patients with an emergent need
for dialysis (eg, volume overload, hyperkalemia) should be
dialyzed through a temporary nontunneled CVC prior to
definitive treatment of their AV access thrombosis.
Detailed Justification
Both endovascular and open surgical approaches for
treating thrombosed AVGs are acceptable, with the choice
determined by the local practice and expertise, underlying
condition, and patient preference. Although earlier reports
suggested superior outcomes with the surgical approach,
more recent reports have suggested that both approaches
for AVGs are comparable, likely reflecting the overall
evolution in the endovascular therapies.431,440,441
Furthermore, there are a number of different endovascular
approaches, although none has proven superior.438
Importantly, open surgical and endovascular approaches
should not be viewed as competing but rather complementary,
because there are a variety of hybrid approaches
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S98 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
that involve both (eg, open surgical thrombectomy with
combined balloon angioplasty of central vein steno-
sis).442,443
There has been a gradual evolution in the
approach to thrombosed AVFs with the earlier version of
the 2006 KDOQI guideline recommending abandoning
the AVF to more recent attempts at AVF thrombectomy and
AV access salvage.395,444
A meta-analysis by Kuhan et al441
emphasized the lack of long-term data with little quality
evidence to guide the management of thrombosed AVFs.
The contraindications to AV access thrombectomy include
pulmonary hypertension and right-left intracardiac shunts
due to the potential risk of embolization and AV access
infection.
Regardless of the approach, thrombectomy should be
performed in a timely fashion relative to the event,
particularly for AVFs, given the pathophysiology of the
thrombotic process and the underlying inflammatory
response. Although it is possible to remove AVG thrombus
up to 30 days, early thrombectomy has been associated
with better long-term results.445
Sadaghianloo et al446
reported that thrombectomy within <6 hours was associated
with a better technical outcome and improved
midterm results. Practically, early thrombectomy helps
minimize and/or eliminate the need for dialysis with a
CVC. However, patients may still require a CVC for dialysis
to manage volume overload or electrolyte abnormalities
prior to AV access thrombectomy.
Although the reported technical success rates for AV
access thrombectomy, both endovascular and surgical,
have been good, the longer-term patency rates have been
poor, underscoring the critical importance of considering
the next AV access option (ie, AV access succession plan)
even before each thrombotic event.438,447,448
Simoni
et al449
reported from a large device registry that the
technical success rate of the AngioJet (Boston Scientific,
Marlborough, MA) percutaneous thrombectomy device
was 92%, although the patency rate for AVGs and AVFs
was 53% and 86%, respectively, at 3 months. Similarly,
Quencer and Friedman438
reviewed that the patency rates
after thrombectomy ranged from 25% to 50% at 6 months
and 10% to 20% at 12 months for both AVGs and AVFs.
Accordingly, repeated thrombectomy of the same AV access
is likely not justified.
Definitive treatment requires identifying and correcting
the underlying cause of the AV access thrombosis.
Completion imaging should be done after either endovascular
or surgical thrombectomy to confirm that the
culprit lesion is corrected.
AV accesses thrombosis within the early postoperative
period (<30 days) is often due to technical issues (eg,
anastomotic stenosis) or the choice of an inadequate artery/vein
combination (eg, diminutive vein) for an AVF.
AV access thrombectomy and/or revision is/are possible
if there is an identified technical defect, although definitive
treatment usually requires constructing a new AV
access. Chemical thrombolysis is a relative
contraindication in the early postoperative period due to
the associated bleeding risk.
Implementation Considerations
All of the HD vascular access types and configurations
have a limited life expectancy and, accordingly, will ultimately
fail or start to fail (ie, failing access). It is
incumbent on the various health care providers who care
for dialysis patients to recognize these dysfunctional accesses
and be familiar with the various failure modes (AV
access complications). Rosenberg et al450
reported that it
is possible to teach nonmedical professionals the requisite
physical examination skills to recognize failing AV access
in a short duration of time. Furthermore, it is important
to engage the patients themselves and challenge them to
assume responsibility for the care and maintenance of
their vascular access. The ultimate goal is to maintain
safe, effective dialysis with the fewest number of interventions
in a patient-centric, cost-effective manner.
Any intervention should consider the impact on current
and future accesses; for example, viable/useful cannulation
segments should be avoided when using stent grafts.
It is the hope that early recognition and definitive treatment
of the failing and thrombosed vascular access will
result in improved vascular access functional survival.
Monitoring and Evaluation
The identification of failing and thrombosed AV access
should be part of the routine monitoring protocols
(Guideline Statement 11.1 and Guideline 13). It is important
for the various health care providers to be cognizant of the
various failure modes such that they can initiate the appropriate
referral and/or remedial treatment, as part of the
vascular access contingency plan. At that time, consideration
and planning for the next dialysis access or kidney replacement
modality (as appropriate) should begin in accordance
with the individual patient’s ESKD Life-Plan strategy.
Future Research
 Define and validate the optimal monitoring strategies
for the dysfunctional AV access
 Define and validate the thresholds for intervention for
the dysfunctional AV access
 Define the optimal open and endovascular treatment(s)
for the dysfunctional and thrombosed AV access
 Define outcome metrics for the dysfunctional and
thrombosed AV access
 Determine outcomes with surgically corrected occluded
AV accesses that are followed by a completion angiogram/imaging
± further corrective procedure(s). How
does this strategy compare with historical surgical
correction without completion imaging or with endovascular
management?
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Guideline 16. AV Access Infection
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: AV Access Infections
Monitoring and Prevention
16.1 KDOQI considers it reasonable to educate the
patient on washing the access arm using antiseptic
to clean the skin prior to every cannulation.
(Expert Opinion)
16.2 KDOQI considers it reasonable to check the
vascular access and surrounding area prior to
every cannulation for signs and symptoms of
infection. (Expert Opinion)
Note: This check should be done by patient and cannulator (if patient
does not self-cannulate).
See special considerations from Guideline Statements
11.2, 11.3, and 11.7 that are relevant to this section.
Diagnosis
16.3 KDOQI considers it reasonable to use radiologic
imaging to help confirm the diagnosis of AV access
infection; however, physical examination
remains the hallmark for assessing for infection.
(Expert Opinion)
Note: Radiologic imaging includes duplex ultrasound, ± CT scan,
PET, and nuclear medicine scans (eg, indium scan).
Note: Signs of infection include erythema, skin breakdown, purulent
discharge, and presence of exposed graft.
16.4 KDOQI considers it reasonable to investigate and
closely monitor for metastatic complications (eg,
endocarditis, spinal abscesses, septic arthritis) in
patients with buttonhole infection from particularly
dangerous organisms such as S aureus, Gramnegative
bacteria, and fungal organisms. (Expert
Opinion)
Note: Investigations include 2D echocardiography, MRI, joint aspirate,
and other, as appropriate.
Treatment
16.5 KDOQI considers it reasonable to obtain cultures
and sensitivities of the blood and any available
infected AV access vessel/material, surrounding
tissue, or drainage prior to initiating antibiotic
therapy. (Expert Opinion)
16.6 KDOQI considers it reasonable for infected
AV access the rapid initiation of empiric
broad-spectrum antibiotics and timely
referral to a surgeon knowledgeable in the
management of vascular access complications.
(Expert Opinion)
16.7 KDOQI considers it reasonable to have strict
follow-up of culture results with the appropriate
change in antibiotics based on organism sensitivities,
with antibiotic duration according to
extent of vascular access infection and surgical
intervention. (Expert Opinion)
16.8 KDOQI considers it reasonable that the specific
surgical treatment for AV access infections
(with concurrent antibiotics) should be based
on the patient’s individual circumstances
considering the extent of infection, offending
organism, and future vascular access options.
(Expert Opinion)
Rationale/Background
Both AVFs and AVGs (collectively referred to as AV
access) can become infected. The underlying mechanisms
are somewhat different, but the management
principles including systemic antibiotics and source
control are similar and grounded on standard principles
of managing infected vascular prostheses. The
incidence of AV access infections is relatively low,
particularly for AVFs. However, the spectrum of potential
sequelae of AV access infections are broad and
range from mild limited cellulitis to extensive graft
involvement mandating total explant; the systemic
consequences can range from localized pain and fever
to overwhelming sepsis and death. Treatment requires
early recognition and management to prevent sequelae.
The definitive treatment of AV access infections should
be chosen within the context of the patient’s ESKD
Life-Plan dialysis access needs, with consideration for
preserving/maintaining future vascular access options.
Prevention and monitoring for ongoing or recurrent
infection are critical. The current recommendations are
consistent with the recommendations from the previous
KDOQI Guidelines.
Detailed Justification
AVF and AVG infections are a major clinical problem, often
leading to hospitalization and increased mortal-
ity.396,451,452
AVG infections have been reported to occur
in up to 1.6% to 35% of patients, with an overall incidence
of positive blood cultures of 0.31/1,000 days.453,454
The
incidence of AVF infections is typically, but not always,
lower,455
and this may be modified by different cannulation
techniques, with buttonhole cannulation putting AVF
at greater risk of infection.303,312,456
AVGs that have been
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S100 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
abandoned in the past are also sources for infection. AVFs
have a median infectious complication rate of 0.11/1,000
days457
and positive blood culture rate of 0.08/1,000
days.458
The underlying mechanisms responsible for the development
of AV access infections are likely multifactorial and
include both patient and system-related issues
(Supplement 4). Skin organisms S aureus and Staphylococcus
epidermidis account for 70% to 90% of AV access in-
fections459-461
in the upper extremity, with a higher
incidence of Gram-negative organisms in lower-extremity
AV accesses.462
AV access infection may be polymicrobial,
with a variety of causative organisms, including
fungi.264,460,463-466
Attaining blood and relevant AV access
cultures (wound, soft tissue, tunnel, or drainage) before
initiating antibiotics is critical.
Patients with AV access infections require timely
detection, diagnosis, and treatment to prevent poor outcomes.
Presenting signs and symptoms range from mild
cellulitis around the cannulation site to bacteremia and
overwhelming sepsis.
The physical examination and routine laboratory studies
are usually sufficient to establish the diagnosis. However,
additional imaging can help corroborate the diagnosis and
define the extent of AV access involvement. In particular,
Duplex ultrasound can be used to confirm patency, interrogate
the integrity of the AV access wall, confirm the
presence of any aneurysms/pseudoaneurysms, document
the presence of fluid around the vein/nonautogenous access,
and help determine the extent of the infection264,467
Ultrasound cannot differentiate the type of fluid around
the AV access (ie, hematoma vs seroma vs abscess), which
requires clinical corroboration. Other imaging studies can
be used, including CT, PET, indium scans, and technetium
scans, although they are rarely necessary and not as universally
available.264,454,467,468
PET and nuclear medicine
scans may help exclude an occult infection in a thrombosed,
nonfunctional AVG.
General Treatment
Blood cultures should always be obtained when an AV
access infection is suspected. Cultures of the infected skin,
soft tissue, AV access site, or tunnel (eg, obvious abscess or
purulent drainage) may help confirm causative organism
and infection source. Cultures should also be obtained at
the time of any surgical intervention or AV access excision.
Antibiotic therapy should be altered accordingly to culture
sensitivity results. Most antibiotic regimens can be
administered with dialysis, avoiding longer-term intravenous
AV access. Consultation with infectious diseases experts
to find the most convenient and appropriate
antibiotic regimen per culture results may be helpful.
PICCs should be avoided in CKD and ESKD patients as
highlighted throughout the guidelines (Guideline 6).
Treatment of AV access infections includes immediate
initiation of broad-spectrum antibiotics (after attaining
relevant cultures) for both Gram-positive and Gramnegative
organism coverage (eg, vancomycin, piperacillin/tazobactam)
and control of the infectious nidus (ie,
source control). Ideally, the infected AV access should be
avoided for dialysis, although it is possible if the infection
is minimal. Otherwise, a CVC should be inserted and used
until the AV access infection is resolved or if, not
salvageable, until a new AV access can be established.
Specific Medical Management
Antibiotics alone may be adequate treatment for limited
localized AV access infections (eg, buttonhole track
infection in AVF). However, the optimal treatment should
be patient individualized, and requires a multidisciplinary
team approach with early involvement of an experienced
AV access surgeon (Supplement 4 AV Access Infections).
Notably, AVG infections can rarely be treated with antibiotics
alone because once the prosthetic material becomes
infected, it is almost impossible to clear the infection.
The optimal duration of antibiotic therapy depends on
the patient’s circumstances and extent of infection. For
example, extensive AV access infections involving the artery
and vein should likely undergo an extended course of
parenteral antibiotics similar to the treatment of patients
with endocarditis (eg, ≥6 weeks); input from infectious
diseases experts is suggested for guidance in complex cases.
Specific Surgical Management
Definitive surgical treatment of AV access infection requires
careful individualized consideration of the extent of the
infection, the offending organism, the type of AV access (ie,
AVF vs AVG), the location of the infection (ie, anastomotic
vs nonanastomotic), the extent of the infection (ie, localized
vs diffuse), the presence of systemic signs, the presence of
bleeding, and, importantly, future dialysis access options.
Both AVF and AVG infections can lead to erosion of the skin
and life-threatening hemorrhage, underscoring the importance
of a timely, definitive surgical treatment as needed.
Surgical treatment options can be broadly categorized as
strategies designed to salvage the AV access and those
designed to excise the AV access (Supplement 4). AV access
salvage options include those for in situ and extra-anatomic
reconstruction (with the reference being the anatomic
course of the infected AV access) for localized infections,
where close follow-up and surveillance are mandatory,
given the risk of recurrent infection and the potential for
anastomotic disruption and significant bleeding. AV access
excision options include strategies for both complete and
subtotal AV access excision and are considered for infections
involving the full length of the AVG (see Supplement 4 for
surgical details).
Key Surgical Management Points to Remember
 Salvage of the AV access may be possible if the infection
is localized; in an AVG infection, this may be possible
Guideline 16. AV Access Infection
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only if the adjacent segments are uninvolved and well
incorporated.
 If the infected segment is limited, graft replacement
through an uninfected field with excision of the
involved segment, may be possible.
 Extensive AV access infections, especially AVG, require
total graft excision with definitive treatment of the
arterial and venous anastomosis.
Note: Potential options include vein patch angioplasty, vein bypass.
and ligation, depending on extent of infection and circumstances.
Preventative strategies should always be used and
include avoiding or limiting CVCs, optimizing the use of
AVFs where appropriate, avoiding the creation of lowerextremity
AV accesses whenever possible, use of autogenous
or nonautogenous biologic grafts in patients at high
risk for infection, use of the appropriate prophylactic
perioperative antibiotics, strict sterile technique at the time
of AV access creation, appropriate cannulation techniques
(Guideline 11), and mandatory routine AV access monitoring
with a low threshold for intervention with any
evidence of infection.
Buttonhole cannulation has been associated with
significantly higher risks of infection compared with
rope-ladder cannulation technique and should be
avoided whenever possible. Buttonhole infections are
more likely to be Gram-positive and more virulent (eg,
S aureus), often with serious metastatic consequences
such as endocarditis, septic arthritis, or spinal abscesses.
Should metastatic complications be detected, rapid
treatment with consultation from infectious diseases
experts is necessary to prevent serious or catastrophic
outcomes.
Special Discussions
Although this information refers to all AV accesses, great
attention must be paid to lower-extremity AV accesses due
their higher complication rate, including infectious complications
(more likely to involve Gram-negative
organisms).58,462,469,470
Early post-AV access creation (<1 month) soft-tissue
infections are commonly associated with the inherent
surgical trauma from creation and/or any break in sterile
technique. They can typically be treated with a course of
systemic antibiotics but require long-term monitoring.
Although the current recommendations build on those
from the previous KDOQI Guidelines, the ERT did not
identify relevant publications for the treatment of AV
access infections using their search criteria. The previous
Guidelines defined outcome measures for lifetime use of
AVF (<1%) and AVG (<10%); however, the current
Guideline has not defined similar measures due to the
lack of appropriate evidence, especially those using
current measures (eg, rates/1,000 access days vs percent
use).
Guideline 17. AV Access Aneurysms
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: AV Access Aneurysms
Recognition and Diagnosis
17.1 KDOQI considers it reasonable to check AV
access for aneurysms/pseudoaneurysms at each
dialysis session by knowledgeable care providers,
including but not limited to dialysis technicians,
nurses, nephrologists, and vascular access coordinator.
(Expert Opinion)
17.2 KDOQI considers it is reasonable to proactively
educate patients on emergency procedures for
aneurysm rupture and to obtain proactive surgical
assessment when clinical findings suggest an
AV access aneurysm/pseudoaneurysm to be at
risk of complications. (Expert Opinion)
Note: An aneurysm/pseudoaneurysm that is considered at risk of
complications is one with evidence of associated symptoms or skin
breakdown.
17.3 KDOQI considers it is reasonable to obtain
emergent surgical assessment and treatment for
AV access aneurysm/pseudoaneurysm complications
such as erosion or hemorrhage. (Expert
Opinion)
17.4 KDOQI considers it reasonable to use duplex
ultrasound to corroborate the physical examination
suggesting an AV access aneurysm/pseudoaneurysm
and to obtain information on the
size, presence of stenosis/thrombus, and impact
on the AV access (including flow rate [Qa] and
status of the arterial inflow and the venous
outflow). (Expert Opinion)
Management
17.5 KDOQI considers it reasonable that the presence
of an aneurysm/pseudoaneurysm alone in
the absence of symptoms (ie, asymptomatic) is
not an indication for definitive treatment.
(Expert Opinion)
17.6 KDOQI considers it reasonable to avoid cannulating
the access segment(s) that involve the
aneurysm/pseudoaneurysm if there are
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S102 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
alternative sites. In the rare scenario where there
are absolutely no suitable alternative cannulation
sites, the sides (base) of the aneurysm/pseudoaneurysm
should be cannulated (ie, avoid the top).
(Expert Opinion)
17.7 KDOQI considers it reasonable to obtain appropriate
imaging of the arterial inflow and venous
outflow to assess volume flow or stenotic problems
that may need correction prior to or during
definitive treatment of symptomatic aneurysm/
pseudoaneurysm. (Expert Opinion)
17.8 KDOQI considers it reasonable that surgical
management is the preferred treatment for patients
with symptomatic, large, or rapidly
expanding AV access aneurysm/pseudoaneurysm
(see “Treatment–Definitive” below). (Expert
Opinion)
17.9 KDOQI considers it reasonable that a definitive
surgical treatment is usually required for anastomotic
aneurysms/pseudoaneurysms. (Expert
Opinion)
Treatment–Definitive
17.10 KDOQI considers it reasonable that open surgical
treatment should be deemed the definitive
treatment for AV access aneurysms/pseudoaneurysms
with the specific approach determined
based on local expertise. (Expert Opinion)
Note: The approach may include a plan for staged repair of multiple
aneurysms to avoid bridging CVCs in the perioperative period.
17.11 KDOQI considers it reasonable to use covered
intraluminal stents (stent-grafts) as an alternative
to open surgical repair of AV access aneurysms/
pseudoaneurysms only in the special circumstances
such as patient contraindication to surgery
or lack of surgical option, due to the
associated risk of infection in this scenario. (Expert
Opinion)
17.12 KDOQI considers it reasonable that, should a stent
graft be used to treat AV access aneurysms/pseudoaneurysm,
cannulation over the stent-graft
segment be avoided when possible. (Expert Opinion)
Note: The use of stent grafts to manage aneurysms/pseudoaneurysms
is not an FDA-approved indication.
Prevention
17.13 KDOQI considers it reasonable that appropriate
cannulation techniques should be implemented
to reduce the occurrence of AV access
aneurysms/pseudoaneurysms (Guideline 11).
(Expert Opinion)
Rationale/Background
The hemodynamic changes resulting from AV access
creation lead to vessel dilatation and AV access
enlargement. These hemodynamic changes are likely
exacerbated by the repeated cannulations and injury to
the vein or graft material and, along with increased
intraluminal pressures from any outflow stenosis, can
cause pseudoaneurysms or aneurysms. The reported
incidence has ranged from 5% to 60% in clinical se-
ries.471,472
Al-Jaishi et al457
reported an incidence of
0.04 per 1,000 patient days. The incidence and natural
history of AV access aneurysms/pseudoaneurysms are
somewhat undefined, partly because of their imprecise
definitions. Aneurysms/pseudoaneurysms can lead to
skin erosion with hemorrhage, AV access dysfunction,
pain, and cannulation difficulties. All symptomatic AV
access aneurysms/pseudoaneurysms with skin erosion/
ulceration and hemorrhage that represent a risk for a
true life-threatening surgical emergency merit immediate
assessment and appropriate treatment. The size of
an AVF aneurysm alone is not an indication for surgical
treatment, although cannulation through the aneurysmal
segment should be avoided. The optimal treatment
approach is individualized to the patient’s AV
access and ESKD Life-Plan, within the constraints of local
expertise. An endovascular approach using a covered
intraluminal stent may be a helpful temporizing measure
in urgent or emergent settings, although it is not recommended
for more routine indications. The current
recommendations are consistent with the previous
KDOQI Guidelines.
Detailed Justification
After creation of an AVF, hemodynamic forces in both the
artery and the vein are altered, leading to an increase in
vessel diameter, blood flow, and blood volume
throughout the circuit. These physiologic changes are
integral to the maturation process of AVFs, although they
can become problematic or pathologic if the outflow vein
continues to dilate and becomes aneurysmal. The presence
of an outflow stenosis leading to increased intraluminal
pressure,473
repeated cannulations, and genetic
predisposition contributes to aneurysm formation. A true
aneurysm is defined as a circumscribed dilation of all 3
layers of the vessel wall, whereas a pseudoaneurysm is
essentially an extraluminal “blood flow through” defect
(ie, hole) in the vessel or prosthetic AV access that is
walled off or contained by the surrounding soft tissue
(Fig 17.1). An aneurysm in the arterial circulation is
defined as a vessel that is 1.5 times greater than the
normal, expected blood vessel diameter (eg, normal
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S103
infrarenal aorta, 2 cm; aneurysmal aorta, 3 cm). The
definition of an aneurysmal AVF is somewhat confusing
because a mature AVF is essentially an “aneurysm” given
the strict definitions for arterial aneurysms. Balaz and
Bjorck471
have attempted to clarify this issue and have
defined an AVF aneurysm as an enlargement of all 3 vessel
layers with a diameter of >18 mm or roughly 3 times the
diameter of the outflow vein of a mature AVF. However,
other classification systems exist.474
Aneurysms can
develop anywhere along the course of the AV access
circuit, including the inflow artery,475
but they typically
occur in the outflow vein. Indeed, the distribution of the
aneurysmal segments in the outflow vein has been used as
part of a classification scheme.474
Pseudoaneurysms usually occur due to vessel wall defects
from repeated cannulations in the same location and
are noted intraoperatively as having Swiss cheese appearance.
Although they develop in AVFs, they are more
common in AVGs. Given the strict definition given, true
aneurysms are unlikely to occur in the prosthetic segment
of an AVG because it requires a dilation of all 3 vessel
walls. Pseudoaneurysms can also develop at the site of
anastomosis in the AVF or AVG, although the responsible
mechanisms are somewhat different and include technical
defects related to the procedure and infection.
The majority of AV access aneurysms/pseudoaneurysms
are typically asymptomatic, but they can be associated with
multiple complications and/or lead to AV access
dysfunction. Most worrisome, the aneurysms/pseudoaneurysms
can lead to thinning and subsequent erosion of
the overlying skin and life-threatening hemorrhage. Jose
et al476
reported that the incidence of AV access–related
fatal hemorrhage (all etiologies, not just related to aneurysm/pseudoaneurysm)
was 1 for every 1,000 patient
years and likely occurs every decade in a dialysis unit.
Aneurysms/pseudoaneurysms often contain laminated
thrombus that compromise AV access function, thereby
limiting available cannulation sites.471
Aneurysms/pseudoaneurysms
can be associated with high-output congestive
heart failure and pain, and they become cosmetically
unacceptable to patients.
The diagnosis of an AV access aneurysm/pseudoaneurysm
is made by physical examination and can be corroborated
with Duplex ultrasound. Ultrasound can also detect periaccess
fluid, intraluminal thrombus, and inflow/outflow
stenoses and quantitate aneurysm/pseudoaneurysm diameter
and intra-access flow rates. It is critical to determine if the
aneurysm/pseudoaneurysm is symptomatic and/or at risk
for ulceration and rupture. Therefore, it is important to have
routine, objective measures of aneurysm/pseudoaneurysm
growth and development, and with greater frequency if
worrisome signs or symptoms develop (Table 17.1). Some
signs and symptoms, such as AV access flow dysfunction,
thrombosis, unacceptable cosmetic appearance, pain, and
COMPLEX
AND
HETERO-
GENOUS
Type 1a: The vein is
dilated almost uniformly
from the arterial anastomosis
along most, if not all,
of its length. The appearance
resembles a hose
pipe.
Type 1b: The proximal part
of the vein is dilated. This is
almost entirely seen within
5 cm of the arterial
anastomosis.
Type 2a: There is at least
one localized dilatation of
the vein, but more often
two. This is the classic
camel hump. These
dilatations appear to
correlate with sites of
needling for dialysis. In
between these localized
aneurysms the vein returns
to normal caliber or is in
some cases, stenosed.
Type 2b: There is both a
post anastomotic aneurysm
and also localized
dilatations. This effectively
is a combination of Type 1b
and Type 2a.
Type 3: These represented
AVFAs which did not fit the
groups above and bore no
resemblance to each other.
There were no typical
features.
Type 4: These may appear
as true localized
aneurysms but on duplex
testing will be shown to be
false aneurysms. An
intraoperative specimen is
shown here.
Figure 17.1. Valentini Classification according to shape of the AV aneurysm. Adapted from Valenti et al666
with permission of SAGE Publications,
Inc; original image © 2014 Valenti et al.
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S104 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
difficult cannulation, are either obvious or are addressed
elsewhere in the Guidelines.
All symptomatic AV access aneurysms/pseudoaneurysms
should be evaluated and managed. Patients with
threatened skin or ulceration overlying their aneurysms/
pseudoaneurysms should be treated urgently or emergently
to prevent significant hemorrhage. Patients with
aneurysm/pseudoaneurysm-related AV access flow
dysfunction, thrombus, or limited cannulation sites
require treatment to maintain AV access to provide
effective dialysis. Patients with high-output congestive
heart failure merit treatment to potentially reverse any
contribution from the AV access. Patients with pain
and/or unacceptable cosmetic disfigurement due to their
aneurysm/pseudoaneurysm need an individualized
treatment plan that considers the risks associated with
potential loss of their AV access. However, aneurysm/
pseudoaneurysm size alone is likely not an indication for
treatment in the absence of symptoms or threatened
skin.471,472
AV access aneurysms/pseudoaneurysms do
not usually spontaneously rupture like aneurysms in the
arterial circulation. However, rapidly enlarging AV access
aneurysms/pseudoaneurysms merit closer followup
and a lower threshold for intervention. Large,
asymptomatic AVG pseudoaneurysms may require
careful monitoring and active treatment because they are
essentially fed by a large opening in the prosthetic
material that is walled off or contained by the surrounding
tissue. Lazarides et al477
have suggested that
12-mm AVG pseudoaneurysms be repaired because they
exceed the typical 6-mm graft diameter 2-fold. All
anastomotic aneurysms/pseudoaneurysms require evaluation
and active consideration for repair because their
etiology and natural history are likely different than
those involving the outflow vein or length of the graft.
Finally, all infected AV access aneurysms/pseudoaneurysms
merit treatment (Guideline 16).
The treatment goals for patients with symptomatic access
aneurysms/pseudoaneurysms should be to prevent
acute complications by managing the precipitating cause
(eg, high inflow or a venous outflow stenosis) and
modifying the involved AV access segment(s), maintain
AV access function, prevent further complications, and
avoid CVC use. Unfortunately, the quality of the available
evidence to guide treatment is limited, and there are no
RCTs. Open, surgical repair remains the standard of care,
and it is feasible to salvage the AV access in the majority of
cases; patency rates after revision range from 52% to 100%
at 1 year.471,472,477-479
The optimal approach and timing are dictated by the
extent of the aneurysm/pseudoaneurysm (ie, focal versus
diffuse), the quality of the involved tissue, and the presence
of any infection. Alternative treatments include
aneurysmorrhaphy and interposition grafting with the
choices among the latter including both autogenous and
prosthetic conduits tunneled in situ or extra-anatomically
(ie, Wang and Wang479
). In certain instances (eg, 2
involved segments), a staged approach may be used to
allow continued access use and avoid a CVC. A variety of
creative aneurysmorrhaphy techniques have been
described involving diameter reduction over a catheter
mandril,480
endo staples,481
and reinforcement with an
external mesh wrap.482
Aneurysmorhaphy may not be
feasible if the vein wall comprising the involved segment is
severely degenerated or calcified, and in situ interposition
grafting with prosthetic material is contraindicated in an
infected field. AV access ligation is an appropriate alternative
to AV access salvage in certain situations but usually
requires excision of the aneurysm/pseudoaneurysm due to
the potential to develop thrombophlebitis and the cosmetic
appearance of the thrombosed segment.472
A full assessment
of the arterial inflow and venous outflow of the AV
access and correction of any contributory lesions is integral
to the treatment algorithm given the high prevalence of
associated lesions.452,471
Any concurrent AV access
dysfunction may be related to culprit high inflow or
outflow stenosis rather than the associated aneurysm/
pseudoaneurysm.
Intraluminal covered stents have been used to treat AV
access aneurysms/pseudoaneurysms.478,483,484
This
endovascular approach is minimally invasive and may play
a significant role as a temporizing measure for patients with
active bleeding or ulceration without compromising future
definitive treatment. The potential downsides to the use of
an intraluminal stent include the potential size mismatch
between the inflow/outflow sections, potential insertion
in an infected field (eg, acute placement for ulceration/
bleeding), potential loss of cannulation zone (secondary to
stent as well as surrounding nonresorbable chronic
thrombus with propensity for infection), and lack of
incorporation within the aneurysm/pseudoaneurysm.
Additionally, covered stents were not designed for
Table 17.1. Physical Examination Findings That Are Clinically Relevant
to Differentiate Between Aneurysm/Pseudoaneurysm That Do Not
Require Urgent Intervention and Those of Urgent Concern
Physical
Examination
Findings
Nonurgent: Monitor Closely
Aneurysm/Pseudoaneurysm
Urgent: Rapid Attention
Aneurysm/
Pseudoaneurysm
Size Not enlarging Enlarging
Overlying skin Can be pinched easily
(supple, mobile skin)
Thin, shiny, depigmented
Skin erosion None Ulcers, scabs
Arm elevation
sign
Collapses May not collapse
Bleeding
from
puncture
sites
Uncommon Often prolonged
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S105
repeated cannulation, and they are not approved by the US
Food and Drug Administration for AV access salvage. Zink
et al484
reported a complication rate of 29% with the use
of covered stents for salvaging AV access, including aneurysms/pseudoaneurysms,
with the specific complications
including migration, fracture, erosion, and rupture.
The optimal treatment for the majority of asymptomatic
aneurysms/pseudoaneurysms is expectant
management or no intervention. The involved segment
of the AV access should not be used for cannulation,
and the cannulation technique should be optimized, as
outlined elsewhere in the Guidelines (Guideline 11).
Indeed, optimal cannulation techniques are critical
through the life cycle of the AV access to help prevent
aneurysm/pseudoaneurysm formation. In the rare
scenario that no alternative cannulation sites are
available, the side of the aneurysms/pseudoaneurysm
(base) that has adequate healthy skin and subcutaneous
tissue should be used (Fig 17.2).485
It is important to
educate patients with aneurysms that are at risk of
bleeding regarding specific emergency measures such
as occluding the inflow of the access and elevation of
the limb above the level of the heart to control
bleeding and calling for help (911), should an aneurysm
rupture.486
There are no published recommendations
for surveillance or serial imaging, although the
AV access should be monitored by physical examination
at each dialysis session per routine as detailed in
the following sections.
The definitive treatment for anastomotic aneurysms/
pseudoaneurysms is dictated by their etiology. Anastomotic
disruption in the early postoperative period due to a
technical reason (eg, suture fracture, inadequate suture
bite) should be treated by revision of the anastomosis.
Those related to infection, typically AVGs, require
removal of all infected material and then arterial repair or
revascularization as outlined elsewhere in the Guidelines
(Guideline 16).
Special Discussions
Skin erosion or active hemorrhage from an AV access
aneurysm/pseudoaneurysm is a surgical emergency that
requires early recognition and definitive treatment. The
bleeding can usually be controlled by direct pressure on
the site or often by occluding the AV access inflow at the
anastomosis and temporized by a suture incorporating the
surrounding soft tissue. Compression of the AV access
outflow (ie, distal to the bleeding site) should be avoided
because it increases the intraluminal access pressure and
potentially increases the bleeding. Patients should be taken
directly to the operating room for definitive repair without
delay, even if the temporary measures are successful in
controlling the hemorrhage.
AV access aneurysms/pseudoaneurysms can contribute
to AV access thrombosis and their presence can complicate
AV access thrombectomy. The treatment strategies for
thrombosed AV accesses with aneurysms/pseudoaneurysm
should consider the management of chronic intraluminal
thrombus and management of the precipitating cause. The
outcomes, particularly for thrombosed AVFs, are likely
inferior to those that do not involve aneurysms/pseudoaneurysms.
Cull et al444
have described a useful technique
that includes an incision over the arterial anastomosis to
remove the arterial plug and then complete thrombus
removal by manually “milking” the thrombus out of the
lumen.
The preceding discussion is relevant for aneurysms/
pseudoaneurysms that involve both AVFs and AVGs.
However, it is worth re-emphasizing that aneurysms
occur only in AVFs and that pseudoaneurysms are primarily
a problem of AVGs that results from degeneration
of the graft due to repeated cannulation in the same
location. Accordingly, the treatment decisions need to
factor in the natural history of the AV access type (ie, AVF
vs AVG), the etiology of the underlying problem, and the
overall ESKD Life-Plan. The treatment of AVG pseudoaneurysms
typically requires an interposition prosthetic
graft tunneled in situ or extra-anatomically with the
choice partially dictated by the presence of any infection;
aneurysmorrhaphy is not an appropriate treatment
option.477
Implementation Considerations
The optimal treatment for patients with AV access aneurysms/pseudoaneurysms,
particularly for patients with
skin ulceration or bleeding, requires early recognition and
definitive treatment. It is incumbent on all personnel who
care for HD patients to recognize the ominous symptoms
associated with AV access aneurysms/pseudoaneurysms
and initiate the appropriate treatment algorithm. Indeed,
AV access ulceration and hemorrhage should be viewed as
a failure of care given the typical thrice-weekly dialysis
sessions. Care should be provided within the context of a
multidisciplinary team involving dialysis technicians,
dialysis nurses, nephrologists, interventionalists, and
Figure 17.2. Creating a longer tract using the lateral approach.
Reproduced from Wilson & Shenoy667
with permission of SAGE
Publications, Ltd; image © 2014 Wichtig Publishing.
Guideline 17. AV Access Aneurysms
S106 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
surgeons involved with vascular access, given the
complexity of the treatment algorithm.
Monitoring and Evaluation
Assessment, Identification, and Documentation
All dialysis providers should be able to assess, recognize,
and diagnose aneurysm/pseudoaneurysm formation in an
AV access. The size of the aneurysm/pseudoaneurysm
should be measured at minimum in 2 dimensions, preferably
with ultrasound imaging (as described) and documented
in the medical records at least every quarter along
with the overlying skin changes. This frequency was
established by consensus of the Work Group given that
there are no published recommendations for surveillance or
serial imaging, although the AV access should be examined
at each dialysis session per routine (as described). Close
monitoring of an enlarging aneurysm/pseudoaneurysm or
those that show signs or symptoms of concern (Table 17.1)
with low threshold for surgical intervention (as described)
should be the guiding principle.
Patients should also be instructed on the appropriate
assessment and monitoring of their AV access and provided
instructions for emergency care and appropriate contacts
for definitive treatment.
Future Research
 Validate the definition and classification schemes for
access aneurysms/pseudoaneurysms.
 Define natural history of AV ccess aneurysms/
pseudoaneurysms.
 Define the optimal treatment strategy for access aneu-
rysms/pseudoaneurysms.
Guideline 18. AV Access Steal
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: AV Access Steal
18.1 KDOQI considers it reasonable that strategies to
both prevent and treat AV access steal should be
developed and implemented before AV access
creation, to reduce the risk of AV access steal and
related morbidity, respectively. (Expert Opinion)
18.2 KDOQI considers it reasonable that post AV access
creation, patients should be monitored
closely for signs and symptoms associated with
AV access steal and managed appropriately with
consideration of individual circumstances as
follows: (Expert Opinion)
 Mild to moderate signs and symptoms require
close monitoring for progression of ischemia
and worsening of signs and symptoms.
 Moderate to severe signs and symptoms often
require urgent treatment to correct the hemodynamic
changes and prevent any longerterm
disability.
18.3 KDOQI considers it reasonable that patients with
signs and symptoms consistent with AV access
steal should be referred urgently to a surgeon/
interventionist familiar with the diagnosis and
options for the definitive treatment of AV access
complications, particularly AV access steal. (Expert
Opinion)
18.4 KDOQI considers it reasonable that the optimal
treatment of AV access steal should be determined
based on the patient’s clinical presentation,
local expertise, and resources. (Expert
Opinion)
Rationale/Background
The construction of an AV access can compromise the
perfusion of the extremity distal to the anastomosis,
resulting in symptoms consistent with acute or chronic
ischemia, commonly referred to as steal syndrome. This occurs
most commonly after brachial artery–based AV accesses,
although it can occur after radial artery–based or
lower-extremity accesses. It may occur shortly after AV
access creation or several years later, with an increase in
intra-access flow or with development of arterial disease of
the inflow and outflow vessels. It is important to consider
strategies to reduce the incidence of steal syndrome
(Table 18.1).
The clinical symptoms of steal syndrome can range
from mild numbness to severe motor compromise, and
from skin ulceration to gangrene that necessitates major
amputation. Several preoperative clinical predictors can
identify patients at high risk of steal syndrome
(Table 18.2) who may benefit from mitigation strategies.
It is important to be familiar with clinical signs and
symptoms (Table 18.3) because the diagnosis is largely a
clinical one, although findings can be corroborated with
noninvasive testing to confirm the hemodynamic changes.
The natural history of steal syndrome is poorly defined,
but moderate to severe symptoms rarely resolve without
definitive treatment. Treatment options (Table 18.4),
Table 18.1. Strategies to Reduce the Incidence of AV Access Steal
Assessment of arterial inflow imaging with correction of inflow stenoses
Correct inflow stenosis or use contralateral extremity
Avoid distal brachial artery–based procedures
Avoid large conduits
Abbreviation: AV, arteriovenous.
Guideline 18. AV Access Steal
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S107
aimed to correct the hemodynamic changes and potentially
reverse the symptoms, should be viewed as complementary
with the optimal choice based on the clinical scenario.
Timely recognition and remediation are crucial to avoid
long-term complications with the ideal goal being to
reverse symptoms and salvage the AV access. The importance
of early recognition of AV access steal and early
referral to an appropriate surgeon (ie, knowledgeable in
the management of AV access steal) were part of the
previous KDOQI Guidelines.13
Special Discussions
As mentioned above, AV access steal occurs less frequently
after radial artery–based AV accesses than after brachialbased
procedures.488,489
Given the dual blood supply to
the hand through the radial and ulnar arteries, the resultant
hemodynamic changes may differ. Notably, the AVF can
serve as a pressure sink that can “steal” blood from the
hand or, more specifically, retrograde flow through the
AVF from ulnar artery and palmar arch can compromise
digital perfusion. The available treatment options are
dictated by the underlying causes of the hemodynamic
changes but include correction of any inflow lesions, flow
reduction, ligation (or embolization) of the distal radial
artery to prevent retrograde perfusion, and AV access
ligation.488-491
The creation of an AV access can result in severe
sensorimotor dysfunction distal to the AV access in the
setting of only mild to moderate ischemia, termed ischemic
monomelic neuropathy.492-494
Although this is likely within the
spectrum of AV access steal, it is a distinct entity that has
been attributed to the development of severe ischemic
neuropathy despite adequate skin and muscle perfusion.
The published experience is somewhat limited, although
the condition appears to be increased among patients with
diabetes, peripheral vascular disease, and preexisting peripheral
neuropathy. Optimal management includes immediate
recognition and treatment, typically with AV
access ligation and observation, although the sensorimotor
symptoms may not be reversible in any approach.495
Implementation Considerations
The development of AV access steal symptoms is one of the
most worrisome complications associated with AV access
creation, given its potential to compromise hand function
and potential for digital ischemia. Accordingly, providers
constructing AV access should be familiar with and assume
complete responsibility of every phase of its management,
including preoperative predictors, diagnosis, strategies to
reduce its incidence, and definitive treatment.
Monitoring and Evaluation
Given the potential for AV access steal to compromise hand
function, all health care providers managing AV access
should be familiar with its clinical presentation and
appropriate initial management, including timely referral
to a surgeon familiar with the various remedial treatments.
Patients should be assessed for the signs and symptoms of
AV access steal as part of routine AV access monitoring and
counseled about the symptoms of steal and the need to
share them with their health care providers.
Future Research
 Further define the pathophysiologic changes that lead to
the development of steal.
 Further define and establish the predictors for AV access
steal.
 Further define and establish strategies to reduce the
incidence of AV access steal.
 Further define the natural history of mild to moderate
symptoms related to AV access steal.
 Further define and validate the diagnostic criteria for AV
access steal.
 Further define the optimal remedial treatments for AV
access steal.
 Further define ischemic monomelic neuropathy as a
distinct entity from AV access steal.
Table 18.3. Signs and Symptoms of Steal
Grade Severity Clinical Presentation Treatment
0 None None None
1 Mild Cool extremity with few symptoms None
2 Moderate Intermittent symptoms during
dialysis, claudication
Intervention
sometimes
3 Severe Ischemic rest pain, tissue loss Intervention
mandatory
Note: Based on the Society for Vascular Surgery Reporting Standards
for AV access steal.487
Table 18.4. Treatment Options for AV Access Steal
Ligation (if symptoms are severe, limb loss at risk, or no other option
available)
Correction of arterial inflow stenosis
Flow limiting or banding
Proximalization of the arterial inflow
Revision using distal inflow
Distal revascularization and interval ligation
Abbreviation: AV, arteriovenous.
Table 18.2. Clinical Predictors of AV Access Steal
Advanced age
Female sex
Diabetes mellitus
Peripheral vascular disease
Large outflow conduits
Multiple prior permanent access procedures
Distal brachial artery–based procedures (ie, near antecubital fossa)
Prior episode of AV access steal
Abbreviation: AV, arteriovenous.
Guideline 18. AV Access Steal
S108 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Guideline 19. Other AV Access Complications
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statement: Management of AVG Seroma
19.1 KDOQI considers it reasonable to carefully
monitor for complications of AVG seroma and
manage based on the patient’s individual circumstances
and the clinician’s best judgment and
discretion. (Expert Opinion)
Note: Operator’s/clinician’s discretion carefully considers both the
patient’s individual circumstances and the operator’s/clinician’s
own clinical experience and expertise (ie, reasonable capabilities
and limitations).
Detailed Justification
Fluid collections or seromas can develop around prosthetic
AVGs in the early postoperative period, frequently
near the anastomoses.496
They may resemble an aneurysms/pseudoaneurysms
(Fig 19.1). The seromas are
likely due to the transudation of fluid through the graft
material itself or disruption of the surrounding lymphatic
channels. Daria et al497
reported the incidence to be 1.7%
among 535 AVGs, with higher incidence among those
with upper arm (vs forearm) AVGs. The presence of
seroma/fluid around the AVG can be confirmed with an
ultrasound. The majority of these early seromas are selflimited
and tend to resolve without any consequence;
however, they can serve as a nidus for infection given
the protein-rich nature of the fluid. Seromas that persist
or develop after the early postoperative period may
necessitate AVG removal and replacement, preferably
with a different material tunneled through a different
anatomic course. Fortunately, the majority of the AVGs
can be salvaged, and the longer-term results are
reasonable.497
Statement: Management of High-Flow AV Access
19.2 KDOQI considers it reasonable to closely monitor
and prophylactically manage AV access with high
flows to avoid serious or irreversible complications
(eg, high output cardiac failure), based on
the patient’s individual circumstances and the
clinician’s best judgment and discretion. (Expert
Opinion)
Note: Operator’s/clinician’s discretion carefully considers both the
patient’s individual circumstances and the operatot’s/clinician’s
own clinical experience and expertise (ie, reasonable capabilities
and limitations).
Note: Close monitoring refers to physical exam and history on routine
dialysis rounds and determination of Qa/CO every 6-12 months,
or more frequently as needed.
Detailed Justification
High-Flow AV Access
Increased flow rates through an AV access can lead to a
host of problems, including high-output congestive heart
failure, pulmonary hypertension, central venous stenosis,
venous hypertension, aneurysmal degeneration of the
AVF, and AV access-related hand ischemia. The exact
threshold to define high-flow access has not been rigorously
validated or universally accepted, although an AV
access flow rate (Qa) of 1 to 1.5 L/min or Qa of >20% of
the cardiac output (Qa/CO) has been suggested.498
AV
access can exacerbate underlying symptoms of congestive
heart failure (eg, shortness of breath and fatigue) and even
lead to high-output failure, similar to traumatic AVF.499
Basile et al500
reported that Qa values of >2.0 L/min
were associated with the occurrence of high-output cardiac
failure, with a sensitivity of 89% and specificity of
100%, whereas a Qa/CO of ≥20% had a sensitivity of
100% and a specificity of 75%. Not surprisingly, symptoms
of congestive heart failure may develop at lower
thresholds in patients with underlying heart disease. The
frequency of determination of Qa/CO is not established;
the Work Group believed a 2-dimensional echocardiogram
every 6 to 12 months to help evaluate for cardiacFigure 19.1. Seroma.
Guideline 19. Other AV Access Complications
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S109
decompensation and changes in Qa/CO, depending on the
patient’s circumstances and local resources, was reasonable.
AV access flow rates can be reduced by using a variety
of flow-reducing therapies or banding (Guideline
18).501-504
Predictably, occlusion of the high-flow AV
access results in a decrease in the cardiac output and
improved oxygen delivery.505
Guideline 20. Treatment and Prevention of CVC
Complications
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statement: Monitoring/Surveillance of CVC
Complications
20.1 KDOQI considers it reasonable to perform a basic
medical history focused on signs and symptoms
of CVC-related complications (eg, dysfunction,
infection) and physical examination or check of
the dialysis catheter, exit site, tunnel, and surrounding
area at each catheter dressing change or
dialysis session. (Expert Opinion)
Rationale/Background
Although no studies have explicitly studied the value of
history, physical examination, check, or inspection for
CVC dysfunction, infection, and migration, they are
fundamental tools for assessing the HD patient. For
example, a history of signs or symptoms of bacteremia/
septicemia in a patient with a CVC, should alert the
clinician to further assess for the possibility of CVC-related
infection. It is common for a patient to appear relatively
well but then complain of symptoms of headache,
nausea, dizziness, and chills and exhibit signs of
vomiting, rigors, and fever 15 to 30 minutes after
HD initiation when a CVC-related infection is present.
These signs and symptoms may be related to endotoxin
release from a CVC containing an infected biofilm,
perturbed by the flow incurred by the initiation of
dialysis.
Inspection of the CVC exit site may reveal cuff
migration that places the CVC at risk of infection and
also physical loss of the CVC. Exit-site infection is
indicated by the presence of erythema, swelling, tenderness
and purulent drainage around the CVC exit and
the part of the tunnel external to the cuff. Signs of
tunnel infection are swelling, erythema, fluctuance, and
tenderness over the CVC tunnel central or proximal to the
cuff.
Inspection of the patient on the side of the CVC may
also indicate central venous stenosis/occlusion. Common
findings are not limited to but include dilated subcutaneous
veins and limb swelling.
Special Discussions
Special discussions from the Work Group included (1) the
frequency required to evaluate the CVC for adequate prevention
of CVC infection and dysfunction and (2) that
prior 2006 KDOQI guideline recommend against exchange
of CVC.
Implementation Considerations
The Work Group discussed implementation considerations,
which included (1) standardizing the use of clinical
questions to ask patients pertaining to CVC complications;
(2) training and update of dialysis nurses/technicians to
identify physical signs of infection, occlusion, stenosis;
and (3) identifying key medical personnel to convey information
and facilitate a subsequent action plan if an
abnormality was identified.
Monitoring and Evaluation
More frequent monitoring and follow-up are required if
an abnormality is suspected or found.
Future Research
 Cost benefit of prophylactic vascular access related history/physical
examination or check
 Testing long-term durability of dialysis catheters
Guideline 21. Catheter Dysfunction
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Statement: Definition of CVC Dysfunction
21.1 KDOQI considers it reasonable to assess for CVC
dysfunction during each HD session using the
following updated definition of CVC dysfunction:
failure to maintain the prescribed extracorporeal
blood flow required for adequate hemodialysis
without lengthening the prescribed HD treatment.
(Expert Opinion)
Background/Rationale
Cuffed, tunneled, dual-lumen CVCs have become an
acceptable form of HD vascular access when an AV access is
not suitable or available, despite the associated high
complication rates and mortality risk.67,455
Maintenance of
CVC patency is paramount to providing adequate HD in
patients requiring CVCs on either a temporary or longterm
basis. A common complication of the CVC is CVC
dysfunction, which is associated with reduced dialysis
adequacy, increased risk of CRBSI,506
and mortality.
Guideline 20. Treatment and Prevention of CVC Complications
S110 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Although several studies have reported on CVC dysfunction,
the rate of occurrence, the time from CVC insertion
to dysfunction, and its effect on patients’ quality of life,
there is no consistency in the definitions used for CVC
dysfunction.506-508
Detailed Justification
The new Guidelines definition of CVC dysfunction differs
from the prior guidelines, which was most suitable
for a conventional dialysis prescription of three times a
week dialysis, for 3-4 hours per treatment. The updated
definition can be applied to a range of dialysis prescriptions
(eg conventional HD, incremental HD, short
daily HD, nocturnal HD, etc). There are several factors
that contribute to the delivery of adequate HD beyond
blood flow, including but not limited to the duration,
frequency and/or type of dialysis, type of CVC, ultrafiltration
variables, degree of recirculation, and weight
of the patient. In fact, blood flow may be misleading as
an indicator of clearance if there is a significant presence
of recirculation, particularly if the lines are reversed.509
Past definitions of CVC dysfunction have included specific
criteria pertaining to blood flow rates, venous and
arterial pressure limits, dialysis adequacy based on urea
kinetics, and other parameters. The 2006 KDOQI
guideline defined CVC dysfunction as failure to maintain
extracorporeal blood flow of >300 mL⁄min at a prepump
arterial pressure more negative than -250 mm
Hg or failure to attain and maintain an extracorporeal
blood flow sufficient to perform HD without significantly
lengthening the treatment time.13
Although it is
important to standardize outcomes within a guideline,
this recommendation was opinion based and has been
interpreted as the need to maintain blood flows >300
mL/min to ensure adequate HD. As a result of these
blood flow recommendations, CVCs are often run in the
reverse configuration, thrombolytic agents such as recombinant
TPA are administered, or CVCs are
exchanged when blood flow is consistently ≤300 mL/
min. Previous comparisons of CVC mean blood flows of
250, 275, and 300 mL/min did not reliably predict
inadequate HD. This was particularly relevant in patients
with weights below 70 kg.510
Furthermore, blood flows
of <300 mL/min are often standard in patients receiving
long-duration HD, such as nocturnal HD or frequent HD
where HD adequacy is excellent.
Additionally, there is uncertainty around the frequency
of abnormality, that is, the number of HD sessions to
include before defining CVC dysfunction. Patients often
experience a single poor HD run with inadequate clearance
and then spontaneously resume good runs, providing
adequate clearance, without an intervention. These intermittent
decreases in clearance can be related to the position
of the patient, transient blood pressure drop, interdialytic
weight gain, higher levels of hemoglobin, transient partial
thrombosis of the CVC that autolyze, and factors not fully
understood. The consequences of such intermittent episodes
of reduced clearance are unclear, likely due to its
variations in frequency and etiologies.511,512
However, the
Dialysis Outcomes and Practice Patterns Study does report
an association between number of inadequate HD sessions
and increased risk of hospitalizations and mortality, but
these data are confounded by HD inadequacy being
attributed to shortened HD sessions.513
It is unknown if a
single session of HD with reduced adequacy, as measured
by urea clearance but with maintained duration of HD, is
associated with the same risk.
The rate of HD CVC dysfunction is variable depending
on the specifics of the definitions. Using a combined set
of 3,364 patients and 268,363 CVC-dependent HD sessions
from Da Vita and the USRDS, CVC dysfunction,
defined as a blood flow (Qb) <300 mL/min occurred in
7.1% of HD sessions, and almost two thirds of patients
had ≥1 CVC dysfunction session; 30% had ≥1 CVC
dysfunction session per month.514
In an RCT of heparin
versus t-PA, CVC dysfunction, defined as peak Qb
of ≤200 mL/min for 30 minutes during a HD treatment,
mean Qb of ≤250 mL/min during 2 consecutive HD
treatments, or inability to initiate HD owing to inadequate
Qb, occurred in 20.0% of patients in the TPA
group and 34.8% in the heparin group. Others have reported
rates varying between 0.5 to 3.0 events per 1,000
catheter-days.515
Implementation Considerations
The KDOQI Work Group offers this definition because it
allows for intrapatient comparisons and respects differences
in definitions of dialysis adequacy used by various
studies, institutions, and jurisdictions. It allows for the
flexibility required when considering various HD prescriptions
according to type, duration, and frequencies of
the dialysis regimen.
HD units may want to consider establishing local definitions
of CVC dysfunction that incorporate their prescription
goals to meet adequacy targets (thereby being
consistent with KDOQI definitions) and documenting
episode(s) of CVC dysfunction at a predetermined frequency
or interval to allow for trending and appropriate
intervention
Future Research
To accurately document the rate of CVC dysfunction
for comparisons within institutions, across jurisdictions
and treatment regimens, it is necessary to standardize
the definition of CVC dysfunction. There is an urgent
need for the nephrology community to re-evaluate the
definition of CVC dysfunction with supporting validation
studies, eg, what are the sensitivity, specificity,
predictive value of various markers, and timing of
intervention for CVC dysfunction? Is earlier intervention
better?
Guideline 21. Catheter Dysfunction
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S111
Statements: Pharmacologic Prevention of CVC
Dysfunction
CVC Connectors to Prevent CVC Dysfunction or
Bacteremia
21.2 KDOQI considers it reasonable to have an individualized
approach to use special CVC connectors
based on the clinician’s discretion and best
clinical judgment. (Expert Opinion)
21.3 KDOQI considers it reasonable to use an antimicrobial
barrier cap to help reduce CRBSI in
high-risk patients or facilities; the choice of
connector should be based on clinician’s discretion
and best clinical judgment. (Expert Opinion)
Intraluminal Agents to Prevent CVC Dysfunction
21.4 KDOQI considers it reasonable that the choice to
use citrate or heparin as a CVC locking solution be
based on the clinician’s discretion and best clinical
judgment, as there is inadequate evidence to
demonstrate a difference in CVC survival or complications
between these locking solutions. (Expert
Opinion)
21.5 KDOQI suggests the use of low-concentration
citrate (<5%) CVC locking solution, if feasible, to
help prevent CRBSI and CVC dysfunction. (Conditional
Recommendation, Low Quality of Evidence)
21.6 KDOQI suggests that TPA may be prophylactically
used as a CVC locking solution once per
week to help reduce CVC dysfunction. (Conditional
Recommendation, Low Quality of Evidence)
21.7 There is inadequate evidence for KDOQI to make a
recommendation on the comparative use of the
following CVC locking agents for CVC dysfunction
or infection prophylaxis: tinzaparin versus unfractionated
heparin, taurolidine/citrate versus heparin
with or without gentamicin, neutral valve
connector (Tego [ICU Medical]) versus citrate
(46.7%) locking solution.
Systemic Agents to Prevent CVC Dysfunction
21.8 KDOQI recommends against the routine use of
prophylactic systemic anticoagulants (eg,
warfarin) for the sole purpose of maintaining or
improving CVC patency, as there is inadequate
evidence of benefit for CVC patency but suggestion
of increased risk of harm (Conditional/Strong
Recommendation, Low Quality of Evidence).
21.9 KDOQI suggests that low-dose aspirin may be
used to maintain tunneled CVC patency in patients
with low bleeding risk (Conditional Recommendation,
Low Quality of Evidence).
Note: CVC refers to tunnelled hemodialysis CVCs unless otherwise
specified.
Rationale/Background
Among incident HD patients in North America, 80%
continue to start with a CVC,516
despite the well-known
complications of central vein stenosis,517
increased risk
of subsequent AVF failure,94,515
and associated likelihood
of persistent use of the CVC beyond 90 days.516,518,519
CVC dysfunction is a common problem and often requires
medical or surgical intervention.520
Use of thrombolytic
agents and/or CVC exchange occurs in 20% to 40%
of patients dialyzing with CVCs.506
Both of the latter interventions
are associated with high costs.521
In many
cases, CVC dysfunction (previously defined by 2006
KDOQI guideline13
as “failure to attain and maintain an
extracorporeal blood flow of 300 mL/min or greater at a
prepump arterial pressure more negative than -250 mm
Hg”) persists. Besides increases in arterial and venous
pressures registered by the dialyzer that necessitate a
decrease in blood flow, CVC dysfunction can result in
significant recirculation, leading to poor clearance and
lower Kt/V. Left untreated, such CVCs require premature
removal when they become nonfunctional522
(ie, with 1
or both lumens that cannot be aspirated).
The onset of CVC dysfunction can occur early or late
after insertion, which may help in determining the etiology
of the problem and guide subsequent management.
Dysfunction noted immediately after the CVC placement is
likely due to the positioning of the CVC, preexisting
vascular abnormalities (eg, central venous stenosis) or
mechanical damage to the CVC (eg, tight suture or
perforation). Dysfunction developing after successful
initial use is usually due to intraluminal or pericatheter
thrombosis, fibrin sheath formation around the CVC,
mural thrombus adhering to the CVC tip, or new central
venous stenosis.
The following section discusses studies evaluating prophylactic
strategies for CVC dysfunction.
Detailed Justification
Connector Maneuvers to Prevent CVC Dysfunction
A closed-system connector has theoretical benefits of
limiting environmental contact with microorganisms,
reducing biofilm formation and consequent CVC dysfunction
and infection. It is left in place during HD sessions and
changed every week. An RCT (n = 66) compared a closedsystem
connector, flushed with saline and attached to the
CVC hubs, to 46.7% trisodium citrate lock to evaluate a
Guideline 21. Catheter Dysfunction
S112 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
composite study endpoint of CVC dysfunction (requiring
fibrinolytic therapy or mean Qb ≤250 mL/min during 2
consecutive dialysis sessions) and CVC-related bacter-
emia.523
There was no difference in the composite outcome
(48% [connector] vs 55% [trisodium citrate]; RR, 0.72;
95% CI, 0.37-1.42]). The 2 groups also did not differ on
the individual components of the composite outcome—dysfunction
or bacteremia. The need for
urokinase to treat thrombotic dysfunction did not differ (14
participants from the connector group and 9 from the trisodium
citrate group; P = 0.20). CVC survival rates (free of
dysfunction or bacteremia) at 1 year were 0.43 in the
connector group and 0.37 in the trisodium citrate group.
The study did not report harms. Therefore, given these
neutral results, KDOQI suggests that the use of the neutral
valve connector be at the discretion of the clinician.
Due to literature search timeline criterion, the ClearGuard
studies and data were not retrieved or reviewed by
the ERT524,525
; however, the KDOQI Work Group believed
it was important to include in this document. The most
recent study by Brunelli et al was a large, 13-month,
cluster-randomized, comparative-effective study that
evaluated ClearGuard HD barrier cap (single-piece device
that applies antimicrobial inside and outside the hub)
versus Tego plus Curos (2-piece device that applies antimicrobial
to the outside of the Tego cap only). The study
outcome was positive blood culture rate as an indicator of
bloodstream infection rate. A total of 40 dialysis facilities
were enrolled (20 facilities in each group). After a 3month
run-in phase, 1,671 patients (826 control group,
845 Tego plus Curos) qualified for the 13-month intervention
phase. The ClearGuard group had 23 positive
blood cultures compared with 75 in the Tego plus Curos
group (83,064 vs 100,042 CVC days, 0.28 vs 0.75 per
1,000 CVC days, respectively). The incidence rate ratio for
CRBSI analysis and access-related blood stream analysis
favored the ClearGuard group (0.37; P = 0.003 and 0.32;
P < 0.001, respectively).525
Guideline Statements 21.2 and
21.3 may be relevant to consider in the context of this
study until a formal ERT review and analysis for the next
Guideline update.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S179-S182.
Intraluminal Agents to Prevent CVC Dysfunction
Anticoagulant Lock to Prevent CVC Dysfunction. Citrate
Versus Heparin. Three European RCTs compared
citrate to heparin CVC lock (total N = 542).526-528
Followup
was 6 months in 2 studies; 1 study reported results in
CVC days.528
Interventions varied across the studies. One
compared a 5% citrate lock to a 5,000 U/mL heparin
lock527
(standard concentrations). Two trials evaluated
higher concentrations of citrate: 1 compared 30% citrate
lock to a 5,000-U/mL heparin lock,528
and 1 compared
46.7% citrate lock to a 5% heparin lock.526
There were
more episodes of nonocclusive clot per session in the 5%
citrate group compared to the 5,000 U/mL heparin group
(14% vs 7%, P < 0.0001).527
All studies reported on the
treatment required for CVC dysfunction. Overall, there was
no statistically significant difference between groups (RR,
1.25; 95% CI, 0.53-1.96]). One high-concentration lock
study and 1 standard-concentration lock study reported no
significant difference between groups for needing treatment
with urokinase.527,528
One study reported no
bleeding complications,526
and 1 study reported significantly
lower incidences of major bleeding episodes (3% vs
11%, P = 0.01) and lower persistent bleeding after insertion
(4% vs 13%, P = 0.005) in the 30% citrate group
compared with the heparin group.526-528
Doses of Citrate. There is inadequate evidence for KDOQI
to make a recommendation on the use of high- versus lowconcentration
citrate as a locking solution for HD CVCs.
This was not included in the summary of statements to
avoid confusion.
One European crossover RCT compared 10% citrate to 5%
citrate (n = 28)556
in tunneled, single-lumen CVCs. Each
treatment arm was followed for 3 months. Nonocclusive clot
formation was noted in 9.5% of HD sessions with 10% citrate
lock and 12.5% of HD sessions with 5% citrate lock (P =
0.04). Urokinase for CVC dysfunction was required in 16
episodes during 10% citrate use and 14 episodes during 5%
citrate use. The difference was not significant. There were no
episodes requiring a urokinase infusion to restore catheter
patency. There were no harms reported.
Doses of Heparin. One RCT529
(n = 75) and 1 observational
study530
(retrospective review of prospectively
collected data; n = 223) compared different heparin
concentrations. The RCT compared 5,000 U/mL to 2,500
U/mL and reported outcomes to 24 hours.529
The
observational study compared 3 different heparin locks
(5,000, 1,000, and 500 U/mL) after CVC insertion with
follow-up to 30 days.530
In the RCT, there were no episodes
of thrombosis within 24 hours in either group.529
The observational study found no significant differences
between heparin concentrations in 2- or 30-day CVCrelated
infection-free survival, CVC related bleeding530
or incidence of blood flow less than 250 mL/min.530
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S183-S193.
Thrombolytic Lock to Prevent CVC Dysfunction.
Recombinant TPA has primarily been used in the
treatment of CVC thrombosis. An RCT comparing TPA
once per week (with 5,000 U/mL heparin lock after the
other 2 HD sessions) to heparin lock 3 times per week,
enrolled 225 participants with both incident (first ever)
and prevalent CVCs.531
For 61% of the participants, the
CVC was their first dialysis CVC. Follow-up was 6 months,
with extended follow-up for those who experienced the
primary outcome of CVC dysfunction. The primary study
outcome of CVC dysfunction was defined as the first
occurrence of decreased blood flow (eg, peak Qb of ≤200
mL/min for 30 minutes during HD, mean Qb of ≤250
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mL/min during 2 consecutive HD treatments, or inability
to initiate HD due to inadequate blood flow) after protocolized
attempts to re-establish patency. There was a
significantly higher occurrence of CVC dysfunction in the
heparin-only group (40/115; 35%) compared with the
TPA group (22/110; 20%) (HR, 1.91; 95% CI,
1.13–3.22) Among CVCs that experienced dysfunction,
the need for TPA for immediate management was significantly
higher in the heparin group (50% vs 18%, P =
0.01). No significant differences were observed
between the TPA and heparin-only groups for reversal of
CVC lines for immediate management of CVC dysfunction
(TPA, 3/22 [59%], heparin 14/40 [35%], P = 0.07)
(or for any serious adverse event (21% [TPA], 30% [heparin];
P = 0.14) or any bleeding (P = 0.93). There is a
paucity of rigorous studies comparing various methods of
installation of thrombolytic agents (eg, dwell, infusion,
push techniques) and their impact on CVC patency outcomes
and complications.
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S179, S181, S194
through S207, and S237-S239.
Other Intraluminal Agents to Prevent CVC Dysfunction.
Taurolidine and Citrate Versus Heparin. RCTs
(total N = 168) that compared a combined taurolidine
and citrate lock (taurolidine/citrate) to heparin lock532,533
and 1 RCT that compared taurolidine/citrate to a
combined gentamicin and heparin lock (gentamicin/
heparin) for prevention of CVC complications were
identified.534
Of the 2 RCTs of taurolidine/citrate versus heparin lock,
1 trial was conducted in the United Kingdom (N =
110),533
the other in the Netherlands (N = 58).532
The UK
study was of tunneled, cuffed CVC with follow-up of
8,129 and 9,642 CVC days in the taurolidine/citrate and
heparin groups, respectively.533
In the Dutch trial, the
majority (76%) of the catheters were for temporary use
and nontunneled CVC (NT-CVC)532
; the median CVC use
was 158 days for tunneled CVCs and 28 days for NT-CVCs
in the jugular or subclavian vein and 7 days for NT-CVC
inserted in the femoral vein.532
In both trials, the intervention
locks contained taurolidine 1.35% and citrate 4%,
and the heparin lock control contained 5,000 U/mL.
In both trials, removal of CVC due to thrombosis/occlusion
did not differ between treatment groups. In the
study of all tunneled CVCs, the need for thrombolytic
therapy at least once was twice as great in the taurolidine/
citrate group compared with the heparin group: 53%
versus 26% (HR, 2.5; 95% CI, 1.3-5.2).533
Solomon et al533
conducted a nonrandomized, 3-arm
study (N = 174) as an extension of the RCT conducted
in the United Kingdom and compared taurolidine
(1.35%), citrate (4%), and heparin (500 U⁄mL) (ie, TCH)
locks versus taurolidine/citrate versus heparin (5,000 U/
mL) locks. There was no significant difference for CVC
survival between groups.533
Need for thrombolysis was
reduced with the TCH lock (n = 106) compared with the
taurolidine/citrate lock (n = 34) (HR, 0.2; 95% CI, 0.06-
0.5) but not the heparin 5,000 U/mL lock (n = 34) (HR,
1.4; 95% CI, 0.5-3.9).535
The UK trial involving tunneled CVCs reported that
heparin-induced thrombocytopenia led to CVC removal in
1 participant in the taurolidine/citrate group and none in
the heparin group.533
The other study reported no adverse
events associated with the use of taurolidine and citrate
lock solution.532
Taurolidine and Citrate Versus Gentamicin and Heparin.
There was one RCT (N = 119) evaluating combined
taurolidine 1.35% and citrate 4% lock (taurolidine/citrate)
versus combined gentamicin 40 mg/mL and heparin
5,000 U/mL lock (gentamicin/heparin).534
Follow-up
was 90 days.
There was no significant difference in the development
of CVC thromboses: 9 (12%) in the citrate/taurolidine
group versus 11 (15%) in the gentamicin/heparin group
(P = 0.63).
Tinzaparin Versus Heparin. One crossover RCT from
Canada (N = 42) compared tinzaparin lock to heparin
lock.536
Participants received each of the locks for 7 weeks.
All had been using CVCs for more than 3 weeks at the time
of enrollment. No significant differences between treatment
arms were observed for CVC removal due to failure.
Use of alteplase for CVC dysfunction was significantly
lower in the tinzaparin group (3.2% vs 6.0% of HD sessions;
P = 0.008).
Tables of studies, evidence quality, and risks of bias are
provided in Supplement 3, Tables S185, S190, S193, and
S208-S217.
Systemic Agents to Prevent CVC Dysfunction
Five studies of systemic anticoagulants for prevention of
CVC complications were identified. Three RCTs and 1
observational study compared a systemic antiplatelet or
anticoagulant agent to placebo or no intervention.537-540
One of the RCTs evaluated an antiplatelet drug
(aspirin),539
and 1 RCT and the observational study
evaluated an anticoagulant (warfarin).538,540
One of the
RCTs compared an antiplatelet (aspirin) and an anticoagulant
(warfarin) to no intervention and to each
other.537
One additional RCT compared systemic anticoagulation
after CVC placement to anticoagulant
delayed until the first CVC thrombosis or dysfunction
event.541
Aspirin. There are 2 RCTs (total N = 223) evaluating
aspirin compared with either a placebo or no intervention
(control group) in participants with
CVC.537,539
One trial was conducted in Iran (N = 185;
follow-up 12 months),539
the other in Saudi Arabia
(N = 38; follow-up not indicated).537
The Iranian trial
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compared low-dose aspirin (80 mg/day) to pla-
cebo,539
whereas the Saudi study compared low-dose
aspirin (81 mg/day) to no intervention.537
Results were mixed for CVC survival outcomes after
systemic antiplatelet therapy versus control. The Iranian
study reported overall mean CVC survival time to be
longer in the aspirin group compared with the placebo
group, 5.3 versus 3.9 months (mean difference, 1.40;
95% CI, 0.28-2.52]).539
The Saudi study reported 68%
of the 19 CVC in the aspirin group to be dysfunctionfree
at 12 months compared with 37% of the 19 CVC
in the no intervention group. The authors reported that
the difference between groups was significant, but the
ERT reanalyzed the results using a Fisher exact test and
found no statistically significant difference.537
In the Saudi trial, there were fewer participants with at
least 1 CVC dysfunction due to CVC thrombosis in the
aspirin group than in the no intervention group (21% vs
47%), but when results were reanalyzed by the ERT using
a Fisher exact test, the difference was not statistically
significant.537
Adverse events did not differ between the aspirin and
placebo groups in the Iranian trial.539
The Saudi study
reported that no participant in either group experienced a
major bleeding event.537
Warfarin. Two RCTs (total N = 213) compared
warfarin to placebo or no intervention.537,540
One trial
was conducted in Canada (N = 174).540
The second trial
represents the other intervention arm of the study from
Saudi Arabia (n = 39) described in the preceding sec-
tion.537
The follow-up periods were 709 to 722
participant-months in the Canadian study and 12 months
in the Saudi study.537
Most of the participants received
tunneled cuffed CVCs (24% received NT-CVC in the
Canadian trial). A low dose of warfarin, adjusted to an
INR of 1.4 to 1.9, was compared with placebo in the
Canadian study.540
The Saudi study compared a warfarin
dose of 2 to 5 mg/day, targeting an INR of 1.5 to 2.0, to
no intervention.537
Both studies reported CVC survival outcomes. The
Canadian study reported that CVC removal for any
reason did not differ between the warfarin and placebo
groups (HR, 0.87; 95% CI, 0.42-1.81]).540
The
Saudi study reported that dysfunction-free CVC survival
at 12 months was higher in the warfarin group
(75%) compared with no intervention (37%) (reported
as P < 0.01 in the publication and P = 0.02
using a Fisher exact test analyzed by ERT).537
The
Saudi trial also reported that 4 (20%) had at least 1 CVC
dysfunction due to CVC thrombosis in the warfarin group
versus 9 (47%) with no intervention, but the difference
was not statistically significant based on the ERT’s reanalysis
with a Fisher exact test.537
In the Canadian study,
need for an intervention for CVC dysfunction did not
differ between the warfarin and placebo groups, at 46%
versus 47%, respectively (HR, 0.90; 95% CI, 0.57-
1.38).540
The Canadian trial reported no difference in major
bleeds between treatment groups540
: 10 (12%) in the
warfarin group and 7 (8%) in the heparin group (RR,
1.43; 95% CI, 0.57-3.58]). The Saudi study reported that
no participant in either group experienced a major
bleeding event.537
One observational study from 2 units in the United
Kingdom (n = 112 participants with 194 femoral
CVCs)538
observed a total of 20,021 CVC days of use.
Prophylactic systemic anticoagulation, typically warfarin
with a target INR of 1.5 to 2.5, was compared with a no
anticoagulation control group. The control group
restricted anticoagulation to patients with CVC
dysfunction requiring repeated treatment with urokinase
locks.
CVC survival, assessed as CVC removal due to occlusion,
did not differ, at 33% in the anticoagulation group and
27% in the control (P = 0.49).
There was no difference in the number of CVC-related
thromboses between groups, 9% in the prophylactic group
compared with 11% (adjusted HR, 0.66; 95% CI, 0.25-
1.72). Major bleeding occurred in 5 (6%) of 80 CVCs in the
prophylactic group and in 4 (4%) of 108 CVCs in the no
anticoagulation group, with an adjusted HR of 1.65 (95% CI,
0.44-6.22). Corresponding rates were 0.7 and 0.4 per 1,000
CVC days.
Warfarin Versus Aspirin. There is inadequate evidence
for KDOQI to make a recommendation or suggestion on
the use of systemic warfarin versus aspirin for the prevention
or treatment of CVC dysfunction. This was not
included in the summary of statements to avoid confusion.
The detailed justification is as follows.
The RCT from Saudi Arabia by Abdul-Rahman
et al,537
with warfarin and aspirin arms compared to
no intervention (described in the preceding section),
also provided data comparing warfarin to aspirin. The
comparative effectiveness study compared a warfarin
group (n = 20) that received a dose of 2 to 5 mg/day,
targeting an INR of 1.5 to 2.0, with an aspirin group
(n = 19) that received 81 mg/day. Patients were followed
for 12 months.
There was no difference between groups for
dysfunction-free CVC survival at 12 months: 75%
(warfarin) versus 68% (aspirin) (P = 0.65) or for at least 1
CVC dysfunction due to CVC thrombosis: 20% (warfarin)
versus 21% (aspirin). No participant in either group
experienced a major bleeding event.
Warfarin Initiated After CVC Placement Versus
Warfarin Initiated After First Thrombosis or CVC
Dysfunction Event. One Italian RCT (total N = 144)
evaluated warfarin initiated 12 hours after CVC placement
(postplacement warfarin group) versus warfarin initiated
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AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S115
after the first thrombosis or dysfunction (postevent
warfarin group).541
In both groups, warfarin was adjusted
to an INR of 1.8 to 2.5; follow-up was 12 months for these
CVCs.
Fewer participants in the postplacement warfarin
group experienced a thrombosis/dysfunction event, 10
(12%; 0.16 events per patient-year) versus 33 (52%;
1.65 events per patient-year) in the postevent warfarin
group. Also, fewer participants in the postplacement
warfarin group required a CVC replacement due to
thrombosis compared with the postevent warfarin group
(2% versus 17%, respectively; RR, 0.14; 95% CI 0.03-
0.62). No participant in either group experienced a
major bleeding event.
Tables of studies, evidence quality, and risks of bias for
this section are provided in Supplement 3, Tables S218-
S232.
Special Discussions
 Several of these solutions, such as citrate and taurolidine,
are not widely available for use in the outpatient
setting in the United States.
 The cost effectiveness of using prophylactic thrombolytic
locking solutions has not been extensively
evaluated.
 Regarding the uses of systemic anticoagulants, the lack
of benefit and the potential risks of harm were deemed
by the Work Group to be concerns, regardless of
whether an INR is targeted (eg, in cases where warfarin
is used; the benefits, risks and harms data for warfarin
prophylaxis used in other vascular access types and
other indications in HD patients were reviewed by the
Work Group), especially given the known challenges of
consistently achieving a target INR and remaining
within the therapeutic range in HD patients.
Implementation Considerations
 Must consider whether each individual dialysis unit has
the resources to implement changes in preventive
locking solutions.
 The use of any intraluminal or extraluminal cleansing
solutions, antiseptics, antibiotics, medicines, or anticoagulants
should be compatible with the CVC material
 When the evidence extracted and analyzed by the ERT
was inadequate to make a recommendation and there
were no associated harms, the Work Group believed it
important to support use based on the clinician’s
discretion and best clinical judgment. The Work Group
did not want to place restrictions but instead want to
encourage future research to provide the necessary evidence
to assist with future clinical practice guidelines
development on these topics.
Monitoring and Evaluation
Close monitoring of adverse events related to locking solutions
such as citrate.
Future Research
 To prevent CVC dysfunction, better diagnostic tools are
required to detect etiology of dysfunction. For example,
further research can evaluate the role of 2-dimensional
echocardiography to diagnose a catheter-related atrial
thrombus.
 The relationship between size of the intraluminal or
mural thrombus and symptoms
 Larger multicenter RCTs evaluating citrate and
taurolidine
 The role of ethanol as a CVC-locking solution
 The role of nitroglycerin-based CVC lock solution
 The benefit of anticoagulant lock over normal saline for
CVC patency has been raised and could be further
researched, given the potential for increased risk of
adverse events with anticoagulant locks542-545
 The cost effectiveness of various doses of prophylactic
TPA in high-risk patients eg, 2 mg vs 1 mg installation)
 Rigorous studies comparing various methods of installation
of thrombolytic agents (eg, dwell, infusion, push
techniques) and their impact on CVC patency outcomes
and complications
Guideline 22: Treatment and Management of CVC
Dysfunction
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Medical Management of CVC
Dysfunction
Conservative Maneuvers
22.1 KDOQI considers it reasonable for a conservative
bedside approach to managing CVC dysfunction
prior to other medical or mechanical interventions.
(Expert Opinion)
Pharmacologic Maneuvers
22.2 KDOQI recommends intraluminal administration
of a thrombolytic agent in each CVC port to
restore function of dysfunctional CVCs due to
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S116 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
thrombosis. (Conditional Recommendation, Moderate
Quality of Evidence)
22.3 KDOQI recommends the use of alteplase or
urokinase plus citrate 4% per limb for restoring
intraluminal CVC blood flow in an occluded CVC.
(Conditional Recommendation, Moderate Quality of
Evidence)
22.4 KDOQI suggests intraluminal administration of
alteplase 2 mg in preference to alteplase 1 mg in
each CVC port to restore function of dysfunctional
CVCs due to thrombosis. (Conditional
Recommendation, Moderate Quality of Evidence)
22.5 KDOQI suggests administering alteplase by the
dwell or push method to treat CVC dysfunction.
(Conditional Recommendation, Low Quality of Evidence)
Rationale/Background
Despite the well-known complications of CVC
use,94,515,517-519
CVCs are used in 80% of all incident
HD patients.516
CVC dysfunction is a common problem
and often requires medical, endovascular, or surgical
intervention520
in 20% to 40% of patients dialyzing
with a CVC.506
This is inconvenient for patients and
costly to the health care system.521
In the 2006 KDOQI
guideline,13
CVC dysfunction was defined as “failure to
attain and maintain an extracorporeal blood flow of 300
mL/min or greater at a prepump arterial pressure more
negative than -250 mm Hg.” Besides increases in arterial
and venous pressures registered by the dialyzer that
necessitate a decrease in blood flow, CVC dysfunction
can result in significant recirculation, leading to poor
clearance and lower Kt/V. Left untreated, such CVCs
require premature removal when they become
nonfunctional522
(ie, with one or both lumens that
cannot be aspirated, and dialysis cannot be delivered).
Interventions to prevent and treat CVC dysfunction
can be categorized by the type of intervention as medical
and mechanical interventions. Medical interventions are
further subdivided into conservative maneuvers and
pharmacologic interventions per se (eg, TPA use). Mechanical
interventions are similarly subdivided into fibrin
sheath disruption, catheter exchange, and CVC removal
with replacement.
Conservative Maneuvers
Due to complex anatomy of the thoracic veins, CVC
malposition is common546
(Guideline 9). In the settings
of superior vena cava (SVC) stenosis (itself
common in HD patients) and venous aberrations that
follow, such as dilatation of the azygous vein, the
likelihood of incorrect CVC positioning is even
higher.547
Even if initially appropriately positioned,
CVCs can migrate spontaneously, most commonly in
the contralateral innominate vein generating an array
of complications.548,549
CVC dysfunction in these cases is due to direct contact
of the CVC tip or its side holes with the vessel wall, causing
obstruction of blood flow. A CVC placed through the left
internal jugular vein may induce thrombus formation even
if its tip moves up into only the upper portion of the
SVC548,549
because of the 90
turn the CVC has to take
from the left brachiocephalic vein into the SVC. If the CVC
length is too short, its tip will be abutted against the right
lateral wall of the SVC, irritating endothelium. If the CVC is
found to be malpositioned within the first week of
placement, it should be exchanged for one of proper size/
length and properly situated. Older CVCs will likely have
fibrous tissue formed around the cuff, necessitating subcutaneous
dissection and subsequent exchange for a new
CVC.
CVC occlusion, a common cause of poor blood flow,
may also be caused by kinking or malpositioning. In these
cases, CVC dysfunction generally emerges during the first
HD session and can be resolved by repositioning if poor
position is the culprit.
Use of Intraluminal Thrombolytic
The initial management of CVC dysfunction involves
bedside maneuvers. Bedside management includes
repositioning the patients (Trendelenburg position) or
the use of rapid saline flushes to dislodge a possible
thrombus.550
Reversal of lumens may provide temporary
respite and allow for completion of the HD treatment.
If these initial bedside maneuvers are
unsuccessful, and the CVC remains dysfunctional (ie,
cannot be used to provide prescribed HD), consideration
should be made for subsequent medical or mechanical
intervention.
Persistent CVC dysfunction may be due to intraluminal
or pericatheter thrombus or development of a fibrin
sheath. Fibrin sheaths may start to develop at the time of
CVC insertion, recruiting platelets and other coagulation
factors and promoting leukocyte adherence.551
Over a
period of days to months, collagen is deposited near the tip
from the venous vessel wall where the CVC is located. If
clotting exceeds the endogenous fibrinolytic system’s capacity,
subsequent CVC thrombosis will ensue.551
The 3
main types of CVC-related thrombi include intraluminal
thrombus, CVC-tip thrombus, and fibrin sheath-thrombus,
the most common type of thrombus. Management is
directed at these types of thrombi.
The evidence supporting the use of thrombolytic agents
for the medical management of CVC dysfunction follows.
One RCT (N = 106) compared intraluminal administration
of the recombinant TPA alteplase (1 mg/mL)
to urokinase (5,000 IU/mL) in completely occluded
CVC552
; both thrombolytics were allowed to dwell over
Guideline 22: Treatment and Management of CVC Dysfunction
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S117
40 minutes. The mean duration since CVC insertion was
246 days, and 31% were femoral CVCs. Outcomes were
assessed after 1 and 10 HD sessions after the initial
alteplase and urokinase administrations. Treatment success,
defined as Qb >200 mL/min after dwell, was not
significantly different between the thrombolytic groups.
Treatment success after 1 dose of alteplase was 95%
versus 82% in the urokinase group (P = 0.06). After 10
HD sessions, CVC function was maintained in 93% of
alteplase recipients and 86% of urokinase recipients (P =
0.23). CVC removal due to treatment failure occurred in
1 (3%) from the alteplase group compared with 7
(13%) in the urokinase group. No serious harms
occurred.
A second RCT (n = 151) compared tenecteplase 2 mg
with placebo (administered over a dwell time of 1 hour) in
dysfunctional CVC, defined as a blood flow rate <300 mL/
min.553
Outcomes were assessed after 1 treatment session.
Treatment success was defined as blood flow rate
(Qb) ≥300 mL/min and an increase of 25 mL/min from
baseline. Success was greater in the tenecteplase group
compared with the placebo group (22% vs 5%). The absolute
mean difference was 17% (95% CI, 6-27; P =
0.004). Rates of CRBSI were low and did not significantly
differ between groups, at 1% and 4% in the tenecteplase
and placebo groups, respectively. There were no significant
harms in either group.
Dose of Intraluminal Thrombolytic
One observational study (N = 237) compared high-dose
alteplase (2 mg) to low-dose alteplase (1 mg) for the
treatment of CVC dysfunction.554
The treatments were
administered over a dwell time of 30 minutes. The timeto-event
outcome was defined as the time interval between
the first alteplase session until CVC removal due to
occlusive thrombus. More CVCs were removed due to
unresolved thrombus-related dysfunction in the low-dose
group compared to the high-dose group: 19% versus
10%, respectively. After adjustment for potential confounding
variables, the risk for CVC removal was much
greater in the low-dose group compared with the highdose
group, with an adjusted HR of 2.75 (95% CI,
1.25,-6.04). Mean survival times were 955 days for the
high-dose group and 782 days for the low-dose group (P =
0.019).
One RCT (n = 81) compared higher-dose urokinase
(100,000 IU lock) with lower-dose urokinase (25,000
IU lock) in participants who experienced CVC thrombosis/dysfunction
during a 3-year study period.555
The
treatments were administered over a dwell time of 1
hour. All participants received warfarin therapy to
prevent CVC-related thrombosis. Nine study participants
with functioning CVC died and were excluded
from analysis. Higher-dose urokinase was more effective
than lower-dose urokinase in restoring adequate
blood flow. Over the 3-year period, 36 and 29
thrombotic events were reported for the higher and
lower-dose urokinase groups, respectively. In the
higher-dose group, adequate blood flow was returned
in all 36 cases after initial treatment 14% (4/29)
compared to the cases in the lower-dose group (P =
0.01). Adequate blood flow rate was restored in the
remaining 25 cases in the lower-dose group with an
additional administration of urokinase 75,000 IU. In
the lower-dose group, 14 of the 29 patients (48%)
required additional urokinase treatments for more than
2 HD sessions after initial urokinase administration,
compared with 3 of 36 patients (8%) in the higherdose
group (P = 0.01). Two in the higher-dose
group (5%) and 12 in the lower-dose group (38%)
(P < 0.05) had CVC changed due to CVC dysfunction
after repeated thrombolytic therapy failed.
Method of Thrombolytic Administration
There was 1 RCT (N = 83) that compared push and
dwell protocols for alteplase (2 mg/mL) administration
for occluded CVC (Qb, <200 mL/min).558
The push
protocol was completed in approximately 30 minutes. In
the dwell protocol, the initial dwell time was 30 minutes.
If the CVC was not functional after 30 minutes,
alteplase was allowed to dwell for an additional 90 minutes.
The majority of participants (71%) had a previous
CVC. Nearly 70% of the study CVC had been previously
treated with alteplase. Treatment success, defined as
Qb ≥300 mL/min for a minimum of 30 minutes and a
minimum of 100 mL/min increase in Qb as a result of
treatment was not significantly different between the
push and dwell groups. Treatment success was 82%
(push) versus 65% (dwell) (P = 0.08). CVC survival,
defined as time from thrombolytic administration to the
next required CVC intervention, did not differ between
the push and dwell groups. After censoring for reasons
other than CVC interventions for dysfunction and infection,
the mean duration before the next required intervention
in the push group was 65.5 days versus 59.3
days in the dwell group (P = 0.77). No serious harms
were reported
Tables of studies, evidence quality, and risks of bias for
this section are provided in Supplement 3, Tables S194-
S207.
Monitoring and Evaluation
Tracking frequency of dysfunctional and embedded CVCs.
Tracking frequency of use of thrombolytic agents to
treat dysfunctional CVCs.
Future Research
The various methods of managing a CVC that is dysfunctional
but also embedded.
Investigate alternate agents, doses, and methods to treat
dysfunctional CVC.
Guideline 22: Treatment and Management of CVC Dysfunction
S118 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Statements: Mechanical Management of CVC
Dysfunction
22.6 KDOQI considers it reasonable that the decision
to perform fibrin sheath disruption during CVC
exchange for CVC dysfunction be based on the
operator’s discretion and best clinical judgment.
(Expert Opinion)
22.7 There is inadequate evidence for KDOQI to make
a recommendation on the efficacy of or method
of fibrin sheath disruption based on CVC patency
outcomes.
22.8 KDOQI considers it reasonable that CVC removal
followed by replacement at a different site should
be the last resort after conservative, medical, and
other mechanical (eg, angioplasty, CVC exchange)
strategies have all failed to treat CVC
dysfunction. (Expert Opinion)
Detailed Justification
Mechanical Endovascular Fibrin Sheath Disruption
Fibrin sheath formation is a frequent cause of CVC
dysfunction, particularly late CVC dysfunction. Recurring
use of thrombolytics should in itself raise suspicion
of the presence of fibrin sheath around the CVC559
—a
problem affecting 40% to 100% of CVCs.560-562
Although thrombolytic therapy has been demonstrated
to have a high immediate success rate of >80% (as
discussed), 2-month patency can be quite low, at
approximately 36%.563
Subsequently, 4 other strategies
for restoration of CVC patency have been evaluated.
Those included CVC exchange, percutaneous fibrin
sheath stripping, angioplasty disruption, and internal
snare maneuver.
One RCT560
(pilot study) and 1 observational study564
address fibrin sheath disruption. In the RCT, patients
with internal jugular CVCs with fibrin sheaths were randomized
to CVC exchange over a guidewire (n = 12) or
exchange over a guidewire with angioplasty sheath
disruption (n = 18). A group of participants with no
sheath was also studied (n = 14). There were 2 measures
of patency: median time to repeat CVC dysfunction and
median time to repeat CVC exchange.560
The median times
to repeat dysfunction were 373 days and 98 days in the
sheath disruption and sheath/no disruption groups,
respectively (P = 0.22), and 849 days in the no sheath
group. The median times to repeat CVC exchange were
411 days and 198 days in the sheath disruption and
sheath/no disruption groups, respectively (P = 0.17), and
879 days in the no sheath group. Blood flow and use of
thrombolytic dwells were also reported.560
Mean Qb
< 300 mL/min was observed in 15% of those with sheath
disruption compared with 22% without disruption and 7%
with no fibrin sheath (no significant differences). There
was greater use of thrombolytic dwells in the sheath/no
disruption group (5.0%) than the sheath/disruption group
(2.1%), but the difference was significant only compared
with the no sheath group (1.8%).
An observational study, using a local institution procedural
database, reviewed all tunneled dialysis CVC
exchanged between January 2008 and December 2011 (n =
163).564
On angiogram, if a fibrin sheath was present, it
was disrupted by angioplasty; if no sheath was present, the
CVC was exchanged over a guidewire. Patency was determined
at 3-month intervals (to 12 months after replace-
ment).564
The 12-month patencies were 43% in the fibrin
sheath disruption group and 52% in the no sheath group.
There was no significant association between fibrin sheath
disruption and CVC failure (adjusted HR, 1.34; 95% CI,
0.87-2.10]). Neither study reported harm outcomes, and
there was no difference in bacteremia rates between groups.
Study details and evidence quality are provided in
Supplement 3, Tables S233-S238.
CVC Salvage, Exchange, and Other CVC Strategies
CVC exchange over a guidewire can be performed safely
and effectively to treat intrinsic CVC-related thrombosis.565
However, there are sound reasons (non-RCT evidence) to
obliterate the fibrin sheath, if detected, before performing
the CVC exchange to prevent early CVC failure after ex-
change.560,566
CVC patency is greater in the absence of
fibrin sheaths than when CVCs are encased by fibrin sheath
(as discussed). Furthermore, Valliant et al,564
reported that
CVC exchange with fibrin sheath disruption did not increase
the risk of bacteremia and subsequent CVC
dysfunction rates compared with simple over-the-wire
exchange. Another retrospective observational study evaluated
CVC exchange procedures comparing CVC exchange
after creation of a new tunnel and exit site (using the
original venotomy site for exchange) (revision group)
versus exchange over a wire using the same exit and
venotomy site (exchange only group).567
In the revision
group, fibrin sheath disruption was also part of the procedure.
Patients with CVC exchange in the revision group
had significantly fewer infections (likely due to nondisruption
of the exit site and fibrin sheath disruption);
repeat procedures were not evaluated.567
CVC exchange via a guidewire is also an effective method
to treat and prolong CVC patency and preserve and save the
exit site, particularly in patients with limited central venous
access sites.568
Guidewire exchange of CVCs has shown to
be safe and easily performed with no increase in infectious
complications, but at the same time providing similar CVC
longevity to de novo CVC insertion.568
CVC Replacement
Central vein stenosis (CVS) remains one of the most
common vascular access–related complications, with an
occurrence rate of up to 40% in prevalent HD patients517
(Guideline 26). CVC removal, therefore, without
Guideline 22: Treatment and Management of CVC Dysfunction
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S119
protection of the stenotic vessel by placement of a wire
across the stenosis, can lead to thrombosis of the central
vessel in which the CVC was placed. In many patients with
a long history of ESKD and vascular access problems, the
internal jugular and femoral veins may become inaccessible,
either due to stenosis or chronic total occlusion.
These patients can exhaust all of their vascular access options
if the clinician leaves stenotic vessels unprotected.
Guideline 23. Catheter-Related Infection
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statements: Definitions of Catheter-Related
Infections
23.1 KDOQI considers it reasonable to consistently use
standardized definitions for CVC-related infections
to allow for comparisons across programs/jurisdictions.
(Expert Opinion)
23.2 KDOQI considers it reasonable to use the KDOQI
VA-2019 definitions of CVC-related infections
(Tables 23.1 and 23.2), which consider the
unique circumstances of a hemodialysis patient.
(Expert Opinion)
Note: In order to harmonize definitions, the KDOQI VA-2019
definitions encompass those of other organizations.
Rationale/Background
Patients dialyzing with a CVC are at increased risks of
catheter-related infection (CRI) and have increased
morbidity, mortality, and health care costs.34,67,179,569
Catheter-related infections alone have a reported incidence
of 1.1 to 5.5 episodes per 1,000 CVC days.171,570,571
The hospitalization and mortality rates for patients
commencing HD with a CVC is high and has been
attributed to the increase in bacteremia/sepsis observed in
concert with an increased use of CVCs.171,569
The financial
and patient costs of hospital admissions, antibiotic use, and
CVC changes associated with CRI have significant
implications.
It is essential that accurate, consistent definitions of CRI
be used to accurately report their occurrences to permit
comparisons of rates of CRI that may influence practices
across jurisdictions in HD patients using CVCs.
Detailed Justification
Several definitions for CRI are cited in the literature, but
without consensus among the various associa-
tions.13,297,319
Table 23.1 lists the definitions from the
Table 23.1. Definitions of CVC-Related Blood Stream Infections
KDOQI-2019 KDOQI-200613
CDC297
IDSA319
Clinical manifestations and at
least 1 positive BC from a
peripheral source (dialysis circuit
or vein) and no other apparent
source, with either positive
semiquantitative (>15 CFU/
catheter segment, hub or tip) or
quantitative (>102
CFU/catheter
segment, eg, hub or tip) culture,
whereby the same organism
(species and antibiogram) is
isolated from the catheter segment
(eg, hub or tip) and a peripheral
source (dialysis circuit or vein)
blood sample. If available, the
following would be supportive:
Simultaneous quantitative cultures
of blood samples with a ratio
of ≥3:1 (catheter hub/tip vs
peripheral [dialysis circuit/vein]);
differential period of catheter
culture versus peripheral BC
positivity of 2 hours.
Definite: Same organism from a
semiquantitative culture of the
catheter tip (>15 CFU/catheter
segment) and from a BC in a
symptomatic patient with no other
apparent source of infection.
Probable: Defervescence of
symptoms after antibiotic therapy
with or without removal of the
catheter, in the setting in which
BC confirms infection, but
catheter tip does not (or catheter
tip does, but blood does not) in a
symptomatic patient with no other
apparent source of infection.
Possible: Defervescence of
symptoms after antibiotic
treatment or after removal of
catheter in the absence of
laboratory confirmation of BSI in a
symptomatic patient with no other
apparent source of infection.
Clinical manifestations and at
least 1 positive BC from a
peripheral vein and no other
apparent source, with either
positive semiquantitative (>15
CFU/catheter segment) or
quantitative (>102
CFU/catheter
segment) culture, whereby the
same organism (species and
antibiogram) is isolated from the
catheter segment and a
peripheral blood sample.
Simultaneous quantitative
cultures of blood samples with a
ratio of ≥3:1 (catheter vs
peripheral)
Differential period of catheter
culture versus peripheral BC
positivity of 2 hours
OR Isolation of the same
organism from semiquantitative or
quantitative culture segment and
from blood (preferably from a
peripheral vein) of a patient with
accompanying symptoms of BSI
and no other apparent source of
infection.
Bacteremia/fungemia in a patient
with an intravascular catheter with
at least 1 positive BC and with
clinical manifestations of
infections (ie, fever, chills, and/or
hypotension) and no apparent
source for the BSI except the
catheter
AND One of the following should
be present: A positive
semiquantitative (>15 CFU/
catheter segment) or quantitative
(>102
CFU/catheter segment)
culture whereby the same
organism (species and
antibiogram) is isolated from the
catheter segment and peripheral
blood.
Simultaneous quantitative BC
with a >5:1 ratio catheter versus
peripheral.
Differential time period of catheter
culture versus peripheral BC
positivity of >2 hours.
Abbreviations: BC, blood culture; BSI, bloodstream infection; CDC, Centers for Disease Control and Prevention; CFU, colony-forming unit; KDOQI,
Kidney Disease Outcomes Quality Initiative; IDSA, Infectious Diseases Society of America.
Guideline 23. Catheter-Related Infection
S120 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
2006 KDOQI guideline, the CDC, and the Infectious Diseases
Society of America (IDSA). Of note, the 2009 IDSA
guidelines acknowledged the hemodialysis CVC as a
separate entity, as did the updated CDC guidelines.297
In
these aforementioned guidelines, the diagnosis of catheterrelated
bloodstream infections (CRBSI) is obtained through
a set of peripheral blood cultures compared with blood
cultures obtained from (1) the arterial or venous CVC hub
meeting quantitative criteria (3-fold higher count of
colony-forming units [CFUs]/mm in the CVC hub culture
compared with the peripheral venous blood culture); (2)
an arterial or venous CVC hub meeting criteria of differential
time to positivity (DTTP), that is, the blood culture
from the CVC hub turning positive at least 2 hours before
the peripheral blood culture; or (3) the hemodialysis CVC
tip growing the same microorganism as the peripheral
venous culture. These mentioned guidelines define the
peripheral venous culture as one taken from a peripheral
vein.
However, the need for a peripheral culture from the
peripheral vein was recently challenged in a study that
determined the applicability of IDSA criteria for the
diagnosis of CRBSI in patients on HD. It determined the
diagnostic characteristics of an alternate “real world”
approach to diagnosing CRBSI with blood cultures obtained
from the dialysis circuit (another peripheral
source) rather than the peripheral vein.12
This study
determined that blood culture results were most sensitive,
specific, and accurate for the diagnosis of CRBSI,
when taken from the HD circuit (the peripheral source)
and the venous CVC hub and least sensitive, specific,
and accurate when taken from any combination with
peripheral vein blood cultures, making venipuncture
unnecessary. This study does have some limitations,
including a low CRBSI rate and the fact that it was
conducted at a single center.
In the present era of accountability for CRBSIs, it is
important to note that the current CDC or IDSA diagnostic
criteria have not been validated in the unique
circumstances of patients with a CVC undergoing HD.
This issue is timely because there are several challenges
that can influence the rate and accuracy of CRBSI
reporting. These include peripheral vein blood cultures
not obtained, either because patient veins cannot be
accessed or an existing vein needs to be preserved for
AV access; suboptimal handling of blood cultures in the
outpatient dialysis unit (eg, variable time period before
culture bottles are placed in an incubator, differences in
temperature during transport to a microbiology laboratory),
and use of antibiotic locks for CRBSI prevention,
which may interfere with diagnosis. Furthermore,
quantitative blood cultures are not routinely available in
clinical practice (ie, limited to research settings), and
the differential time to positivity criteria has been
found to be met in less than one third of cases.
The 2019 NKF-KDOQI CRBSI definition (Table 23.1) is
as follows: Clinical manifestations and at least 1 positive
blood culture result from a peripheral source (dialysis
circuit or vein) and no other apparent source, with either
positive semiquantitative (>15 CFU/catheter segment, hub
or tip) or quantitative (>102
CFU/catheter segment, eg,
hub or tip) culture, whereby the same organism (species
and antibiogram) is isolated from the catheter segment
(eg, hub or tip) and a peripheral source (dialysis circuit or
vein) blood sample.
If available, the following would be supportive:
simultaneous quantitative cultures of blood samples with a
ratio of ≥3:1 (catheter hub/tip vs peripheral [dialysis
Table 23.2. Definitions of CVC Exit Sites and Tunnel Infections
KDOQI 2019 KDOQI 200613
CDC297
IDSA319
Exit Site Infection
Hyperemia,
induration, and/
or
tenderness ≤2
cm from
catheter exit
site. May be
associated with
drainage from
the exit site. It
may or may not
be associated
with
bacteremia. If
there is exit site
drainage, it
should be
collected and
sent for Gram
staining,
culture, and
sensitivities.
Inflammation
confined to the
area surrounding
the catheter exit
site, not
extending
superiorly
beyond the
cuff if the
catheter is
tunneled, with
exudate culture
result confirmed
to be positive.
Erythema or
induration within
2 cm of the
catheter exit site,
in the
absence of
concomitant BSI
and without
concomitant
purulence.
Hyperemia,
induration, and/
or
tenderness ≤2
cm from
catheter exit site.
May be
associated with
fever and
purulent
drainage from
the exit site. It
may or may not
be associated
with bacteremia.
If there is
purulent
drainage, it
should be
collected and
sent for Gram
staining and
culture.
Tunnel Infection
Tenderness,
hyperemia, and/
or induration that
extends along
the
subcutaneous
tunnel. It may
or may not be
associated
with bacteremia.
If there is
drainage, it
should be
collected and
sent for Gram
staining, culture,
and sensitivities.
The catheter
tunnel superior
to the cuff is
inflamed, painful,
and may have
drainage
through the
exit site that is
culture positive.
Tenderness,
erythema, or
site induration
>2 cm from the
catheter site
along the
subcutaneous
tract of a
tunneled
catheter, in the
absence of
concomitant
BSI.
Tenderness,
hyperemia, and/
or induration
that extends >2
cm from the exit
site and along
the
subcutaneous
tunnel. It may or
may not be
associated with
bacteremia. If
there is purulent
drainage, it
should be
collected and
sent for Gram
staining and
culture.
Abbreviations: BSI, bloodstream infection; CDC, Centers for Disease
Control and Prevention; KDOQI, Kidney Disease Outcomes Quality
Initiative; IDSA, Infectious Diseases Society of America.
Guideline 23. Catheter-Related Infection
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S121
circuit/vein]) and differential period of catheter culture
versus peripheral blood culture positivity of 2 hours.
The 2019 NKF-KDOQI CRBSI definition presented
earlier represents a modification of the previous KDOQI
and other societal guidelines based on the current
evidence.
Table 23.2 provides the minimally revised 2019 NKFKDOQI
definitions for exit-site infection and tunnel infections
in addition to the previous 2006 KDOQI guide-
line,9
IDSA,11
and CDC10
definitions.
Special Discussions
The KDOQI Work Group discussed the importance of
good CVC connections and its contributory role in CRBSI
when not done properly. CVCs should be accessed and
manipulated only by personnel trained and experienced in
hemodialysis CVC care (Guideline 11).
Implementation Considerations
Standardized use of CRBSI definitions among dialysis
providers to ensure consistent reporting and to allow
comparisons between populations/units.
Future Research
 Validate criteria for diagnosis of CRBSI in HD patients
 Further validation studies of diagnostic criteria for exit
site and tunnel infections in HD patients
Guideline 24: Prevention of CVC-Related
Infection
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statement: General Prevention of CVC Infection
and Use of Infection Surveillance Programs and
Infection Control Teams
24.1 KDOQI considers it reasonable for an infection
control program to include an infection surveillance
team to monitor, track (in an electronic
database), help prevent, and evaluate outcomes of
vascular access infections and, in particular, CVCrelated
infections. (Expert Opinion)
Rationale/Background
The key to reducing infections in HD patients is
incorporating an infection surveillance program. There
are several studies documenting that an infection surveillance
program can assist in identifying CVC-related
infections and result in timely interventions to monitor
and treat CVC-related infections and maintenance
strategies to prevent CVC-related infections.572-574
Successful
surveillance programs require dedicated teams
and resources (including use of an electronic infection
tracking system) to monitor clinical outcome measures
such as CVC-related infection rates, hospitalizations, and
death.572
Participation in the CDC’s National Healthcare
Safety Network for bloodstream infection surveillance is
encouraged. Multidisciplinary teams have been shown to
play an important role in implementing effective surveillance
programs.575
Having a dedicated vascular access
nurse or coordinator to assist physicians and staff with
management of CVC-related infections has been reported
to reduce CVC treatment failure rates and death from
sepsis.177-179
However, probably the most effective
strategy to reduce CVC-related infections is avoiding the
use of CVCs. Previous studies have also reported that
programs that have implemented a vascular access
coordinator and vascular access protocols increase use of
AVF as the initial vascular access at HD initiation and
reduce total number of CVC days.168
Specific Prevention of CVC-Related Infection
Routine Monitoring per Guideline 20 is required for the
prevention of CVC complications, including CVC-related
infections.
Statement: Surveillance of CVC Colonization and
Preemptive CRBSI Management
24.2 There is inadequate evidence for KDOQI to support
routine CVC surveillance cultures for colonization
and subsequent pre-emptive antibiotic
lock installation if culture is positive.
Rationale/Background
Surveillance of CVC Colonization
CVCs routinely develop a biofilm on their inner surface,
often within 24 hours of their insertion. Bacteria in
biofilm are a primary source of CRBSI in HD patients
with CVCs. It is likely that if the bacterial burden in the
biofilm is high, this will result in positive surveillance
cultures of the CVC lumen. One potential approach to
preventing CRBSI in patients with CVCs is to perform
periodic cultures of the CVC lumen immediately before a
HD session. Hypothetically, if the culture results are
positive, the patient could receive a course of intraluminal
antimicrobial lock therapy to eradicate the bacteria
in the biofilm.
Detailed Justification
This approach was evaluated in a single-center observational
study of 104 patients with tunneled CVC at a hospital
in Spain.576
During a 1-year intervention period,
patients underwent surveillance blood cultures from the
Guideline 24: Prevention of CVC-Related Infection
S122 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
CVC lumen every 15 days. If the cultures grew coagulasenegative
Staphylococcus species within 14 hours or if they
grew another pathogen (S aureus, Enterococcus species, or
Gram-negative bacteria) at any time, the patient received a
2-week course of an antibiotic lock at the end of each HD
session. The primary outcome, CRBSI, occurred at a frequency
of 0.27 episodes/1,000 CVC days during the
intervention period versus 1.65 episodes/100 CVC days
during the historical control period (no surveillance blood
cultures). The authors concluded that this approach could
triage patients at high risk of CRBSI, who might benefit
from prophylactic antibiotic locks. The ERT graded the
quality of this study as very low, with moderate risk of
bias.
Special Discussions and Implementation
Considerations
The KDOQI Work Group committee had several concerns
about this approach, as follows:
 The quality of evidence was graded as “very low” by the
ERT.
 This was not an RCT, and moderate bias was evident.
The intervention group was compared to a historical
control group rather than to a concurrent control
group, raising the possibility that the reduction in
CRBSI was due to more meticulous aseptic technique,
rather than the surveillance and preemptive antibiotic
lock.
 This is an extremely labor-intensive and expensive
approach. Specifically, in the course of the study,
1,734 surveillance blood cultures were obtained, of
which 94.2% had negative results, and 4.6% grew
coagulase-negative Staphylococcus species in >14 hours.
In other words, only 1.2% of cultures resulted in
treatment with an antibiotic lock. It is unlikely
that such an approach would be feasible in usual
clinical practice. Clearly, an indiscriminate approach
to CVC surveillance cultures for catheter-related
infection is not feasible in normal practice. However,
additional studies would be helpful to identify subgroups
of patients who may benefit from frequent CVC
surveillance cultures and preemptive management of
CRBSI.
 It is important to highlight that CVC surveillance cultures
are very different from surveillance for catheterrelated
infections (which the KDOQI Work Group refers
to as monitoring, and strongly supports).
Future Research
 In addition to determining subgroups of patients who
may benefit from CVC surveillance cultures and preemptive
management of CRBSI (as described), rigorously
designed and implemented studies are required to
determine an effective CVC surveillance culture and preemptive
management strategy for CRBSI in subgroups
of patients at high risk.
Statements: Methods to Prevent CRBSI
Extraluminal Strategies
See Guidelines 11, 21, and 24 on “CVC System Connect
and Disconnect Procedure Considerations” and section on
“Prevention of CVC Dysfunction.”
Intraluminal Strategies
24.3 KDOQI suggests that the selective use of specific
prophylactic antibiotic locks can be considered in
patients in need of long-term CVC who are at
high risk of CRSBI (eg, multiple prior CRSBI),
especially in facilities with high rates of CRBSI
(eg, >3.5/1,000 days). (Conditional Recommendation,
Low-Moderate Level of Evidence).
Note: Under these circumstances and given the current data, KDOQI
considers it reasonable for prophylactic use of specific antibiotics:
cefotaxime, gentamicin or cotrimoxazole (TMP-SMX). KDOQI
cannot support the routine prophylactic use of antibiotic locks
with very low supporting evidence (Table 24.1).
24.4 KDOQI suggests that the selective use of specific
prophylactic antimicrobial locks can be considered
in patients in need of long-term CVC who
are at high risk of CRSBI, especially in facilities
with high rates of CRBSI (eg, >3.5/1,000 days).
(Conditional Recommendation, Low-Moderate Quality of
Evidence)
Note: Under these circumstances and given the current data, KDOQI
can support the prophylactic use of methylene blue. KDOQI
cannot support the routine prophylactic use of antimicrobial locks
with very low supporting evidence (Table 24.1).
24.5 KDOQI suggests that the selective use of once
weekly prophylactic CVC locking with thrombolytic
agent (recombinant TPA) can be
considered in patients in need of long-term CVC
who are at high risk of CRSBI, especially in
facilities with high rate of CRBSI (eg, >3.5/
1,000 days). (Conditional Recommendation, Moderate
Quality of Evidence)
Note: Under these circumstances and given the current data, KDOQI
can support the prophylactic use of recombinant TPA.
Note: High-risk patients refers to those with prior multiple CRSBI, S
aureus nasal carriers.
Rationale/Background
In patients with CVCs, the bacterial biofilm coating the inner
surface of the CVC is the majorsource of CRBSI.577
Instillation
of an antibiotic or antimicrobial lock (in conjunction with an
anticoagulant) into the CVC lumen at the end of each HD
session may reduce CRBSI by sterilizing the biofilm.
Guideline 24: Prevention of CVC-Related Infection
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S123
Detailed Justification
CVC Antimicrobial Caps
Please see the discussion on the ClearGuard cap in
Guideline 21, under Detailed Justification (connector
maneuvers to prevent CVC dysfunction).
Intraluminal Lock Solutions
Please also see the discussion in Guideline 21, under
Detailed Justification (other intraluminal agents to prevent
CVC dysfunction).
Published RCTs have evaluated a large number of
antibiotic CVC lock solutions (gentamicin, cefazolin,
cefotaxime, vancomycin, linezolid, vancomycin plus
gentamicin, cefazolin plus gentamicin, cotrimoxazole
(TMP-SMX), minocycline, or antimicrobial CVC lock solutions
(taurolidine, 30% citrate, ethanol, EDTA, methylene
blue). Most of these (fairly short-term) studies have
demonstrated a substantially lower frequency of CRBSI
with an antibiotic or antimicrobial lock solution,
compared with an anticoagulant lock solution (such as
heparin) (Table 24.1). It is also evident that, in general,
the reduction of CRBSI with an antibiotic or antimicrobial
lock solution was greatest in studies that observed a relatively
high CRBSI rate in the control (anticoagulant-only
lock) group.
Table 24.1. Intraluminal Strategies: Effect of Antibiotic and Antimicrobial Catheter Lock Solutions on CRBSI: Summary of Randomized Clinical Trials
Agents Studied
Patients,
n
Relative Risk
(95% CI) Anticipated Incidence of CRBSI (95% CI)
Quality of
Evidence
Locking Solutions That Can Be Used Selectively for CRBSI Prophylaxis
Cefotaxime593-595
(3 RCTs)
227 0.42 (0.25-0.72) Without antibiotic: 67.5% With cefotaxime: 23.6% Moderate
Gentamicin583-
585,596
(4 RCTs)
555 0.18 (0.07-0.46) Without antibiotic: 22.1% With gentamicin: 4.0% (1.5-
10.2)
Moderate
Weekly TPA506
(1 RCT)
225 0.30 0.11-0.85) Heparin: 13% Weekly TPA: 5% Moderate
Cotrimoxazole597
(1 RCT)
87 0.16 (0.04-0.69 Without antibiotic: 4.4 per
1,000 days
With antibiotic: 0.58 per
1,000 days
Low
Methylene blue598
(1 RCT)
407 0.29 (0.12-0.70) Heparin: 0.82 per 1,000 days Methylene blue% 0.24 per
1,000 days
Low
No Significant Effect or Very Low Evidence, Cannot Be Recommended (below)
Taurolidine/citrate533,599
183 0.49 (0.20-1.24) Heparin: 21.5% Taurolidine/citrate: 10.5% (4.3%-26.7%) Low
Vancomycin or linezolid600
(1 RCT)
152 Without antibiotic:
6.7 per 1,000 days
With vancomycin: 1.2 per 1,000 days
With linezolid: 0 per 1,000 days
Very low
Vancomycin + gentamicin601
(1 RCT)
86 0.18 Without antibiotic:
4.0 per 1,000 days
With antibiotic: 0.7 per 1,000 days Very low
Cefazolin602,603
(2 RCTs)
159 0.58 (0.32-1.04) Without antibiotic: 29.3% With cefazolin: 17.0% (9.4%-30.5%) Very low
Cefazolin + gentamicin604
(1 RCT)
120 0.14 Without antibiotic:
3.12 per 1,000 days
With antibiotic: 0.44 per 1,000 days Very low
Minocycline605
(1 RCT)
204 0.32 (0.14-0.71) Without antibiotic:
4.3 per 1,000 days
With antibiotic: 1.1 per 1,000 days Not reviewed
by ERT
Antimicrobial solutions
EDTA606
(1 RCT)
117 0.34 (0.04-3.24) Heparin:
1.08 per 1,000 days
EDTA:
0.14 per 1,000 days
Very low
Ethanol/heparin607
(1 RCT)
49 0.17 (0.02-0.63) Heparin: 13% Ethanol/heparin: 4% Very low
Ethanol/citrate608
(1 RCT)
40 Heparin: 5% Ethanol/citrate: 0% Very low
Hypertonic saline544
(1 RCT)
59 — Heparin: 10% Hypertonic saline: 15% Very low
30% citrate528
(1 RCT)
291 (0.13-0.36) Heparin:
4.1 per 1,000 days
30% citrate:
1.1 per 1,000 days
Not reviewed
by ERT
46.7% citrate526
(1 RCT)
232 — 46.7% citrate:
0.7 per 1,000 days
Heparin:
0.7 per 1,000 days
Not reviewed
by ERT
Abbreviations: CRBSI, catheter-related bloodstream infection; EDTA, ethylenediaminetetraacetic acid; ERT, evidence review team; RCT, randomized
controlled trial; TPA, tissue plasminogen activator.
Guideline 24: Prevention of CVC-Related Infection
S124 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Antibiotic locking agents that had at least moderate
evidence for prophylaxis against CRI are discussed in the
following sections.
Cefotaxime. Overall CVC-related infections (including
CRBSI) based on survival time were significantly lower
with cefotaxime locks compared with heparin locks in
tunneled CVCs.578
Four RCTs compared cefotaxime (10
mg/mL) and heparin (5,000 U/mL) locks to heparin
(5,000 U/mL) alone578-582
; of these, 3 specifically indicated
use of tunneled, cuffed CVC (N = 30579
to more than
100,581,582
with follow-up of 2-12 months). Total sample
size could not be determined because of uncertainty about
overlap in the separate reporting of the elderly and diabetic
populations. The fourth study (n = 208) enrolled those
with nontunneled temporary catheters (NT-CVC).580
Two studies reported that CRBSI related mortality was
lower in the cefotaxime lock groups compared with the
heparin lock groups. The difference was not statistically
significant in 1 study (10% vs 21%; OR, 0.43; 95% CI,
0.18-1.03).578
In the other study, it was statistically significant
for the elderly group (12% vs 31%; OR, 0.31; 95%
CI 0.12-0.81)582
but not the diabetic group (10% vs 23%;
OR, 0.37; 95% CI, 0.12-1.17).581
The range of CRBSI rates in both the control and
cefotaxime groups were relatively wide,578
although
similarly observed in the studies of elderly (1.7 per 1,000
CVC days [cefotaxime] vs 3.6 per 1,000 CVC days [heparin])
and diabetic (1.6/1,000 CVC days [cefotaxime] vs
3.7/1,000 CVC days [heparin])581,582
participants.
Infection-free survival was found to be significantly higher
in the cefotaxime lock groups compared with the heparin
lock groups (Fig 24.1).
In the study of temporary NT-CVC, the CRBSI rate was
also significantly lower in the cefotaxime lock group (1.7/
1,000 CVC days [cefotaxime] vs 3.1/1,000 CVC days
[heparin]).580
This study also reported CRBSI rates by CVC
location580
and found CRBSI rates for femoral vein CVCs
(2.16 vs 5.78/1,000 CVC days; P = 0.0001), subclavian
vein CVCs (1.16 vs 2.43/1,000 CVC days; P = 0.046), and
internal jugular vein CVCs (1.62 vs 3.25/1,000 CVC days;
P = 0.036) to be lower in those receiving cefotaxime.
See the tables in this section for study quality of evidence
and bias.578-582
Gentamicin. The incidence of CRI was lower in the
gentamicin/anticoagulant locks compared with heparin
locks.
4 RCTs583-586
and 3 observational studies587-589
evaluated
gentamicin combined with an anticoagulant lock to
anticoagulant locks alone for prevention of
CRI.583,585,586,590
One of the studies also compared
gentamicin to minocycline/EDTA585
and the other to
taurolidine534
(Table 24.1)
The 4 RCTs enrolled a total of 555 (range, 41-303)
participants, and follow-up periods in total CVC days
ranged from less than 3,300 in 2 trials,583,585
approximately
18,000 in 1 trial,586
and nearly 40,000 in 1 trial.590
Two trials were conducted in the United Kingdom,583,590
1 in the United States,585
and 1 in China.586
Three trials
compared gentamicin 4 or 5 mg/mL in either 3% cit-
rate585
or heparin only (5,000-5,500 U/mL) locks to
heparin (5,000-5,500 U/mL) locks.583,585,586
One trial
(n = 303) compared lower-concentration gentamicin 320
μg/mL in 4% citrate lock to lower concentration heparin
1,000 U/mL lock.590
Overall, the 4 RCTS showed a significant reduction in
the incidence of CRBSI in the gentamicin/anticoagulant
group versus the heparin group (RR, 0.18; 95% CI, 0.07-
0.46]).583,585,586,590
There were no significant differences
between treatment groups in the incidence of exit site
infections.585,586,590
Harms associated with preventive procedures were
sporadically reported, and events were few (Supplement 3,
Table S244).
Cotrimoxazole (TMP-SMX). A single RCT enrolled
patients with prevalent subclavian (tunneled) CVC and
compared cotrimoxazole (trimethoprim-sulfamethoxazole
[TMP-SMX]) (10 mg/mL) and heparin (2,500 U/mL)
lock to heparin (2,500 U/mL) lock alone.591
Median
Studyname Statistics for eachstudy Events / Total Risk ratioand95%CI
Risk Lower Upper
ratio limit limit Cefotaxime Heparin
Saxena 2012 1.99 1.36 2.91 33 / 41 19 / 47
Mortazavi 2011 3.44 1.57 7.58 15 / 15 4 / 15
Saxena 2006 diabetic 2.63 1.68 4.12 37 / 51 16 / 58
Saxena 2006 elderly 2.14 1.42 3.23 40 / 59 19 / 60
0.1 0.2 0.5 1 2 5 10
Favors Heparin Favors Cefotaxime
Meta Analysis
Figure 24.1. Catheter infection-free survival. Abbreviation: CI, confidence interval.
Guideline 24: Prevention of CVC-Related Infection
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S125
duration of dialysis was 45 days in the intervention group
and 31 days in the control group, with a follow-up of 6 to
12 months.
CRBSI occurred in 4% of the cotrimoxazole group
(0.58/1,000 CVC days) and 27% of the heparin group
(4.4/1,000 CVC days) (P = 0.002). Cumulative CRBSIfree
survival by 365 days was significantly higher in
the cotrimoxazole group (77%) compared with the
heparin group (47%) (P = 0.02). There were no CRBSIrelated
deaths. Two of 41 participants (5%) in the
heparin-only group were hospitalized after detection of S
aureus resistant to cotrimoxazole. There were no adverse
reactions due to the cotrimoxazole lock solution.
Weekly TPA Locks. A Canadian, multisite, doubleblind
RCT (N = 225 patients) of incident CVC
compared TPA lock once weekly (1 mg per CVC
lumen) and heparin lock (5,000 units/mL) twice
weekly versus heparin lock thrice weekly. During a 6month
follow-up, definite or probable CRBSI occurred
at approximately one third of the rate in the patients
receiving weekly TPA locks as compared to standard
heparin locks (4.5% vs 13%). The frequency of CRBSI
was 0.40 and 1.37 per 1,000 CVC-days, respectively.
Methylene Blue Locks. A multicenter US open-label
RCT (N = 407) compared a lock solution containing
0.15% methylene blue, 0.15% methylparaben, and 7%
sodium citrate to standard heparin locks (5,000 units/
mL).592
Patients were followed for 6 months for a total
of 49,565 CVC-days. The occurrence of CRBSI was
significantly lower in the methylene blue group than in
the heparin group (0.24 vs 0.82/1,000 CVC-days; P =
0.005). There was no difference in interventions to
restore CVC patency between groups (16.4 vs 14.8%,
P = 0.38). Of note, after review and retraining of best
practices in establishing a baseline practice for the
conduct of this study, the control group achieved a low
rate of CRBSI of 0.8 episodes/1,000 CVC days.
Tables of studies, evidence quality, and risks of bias for
this section are provided in Supplement 3, Tables S179,
S181, S237-S239, and S240-S251.
Special Discussions
Several RCTs have found that the use of prophylactic
antibiotic or antimicrobial locks reduces the frequency
of CRBSI, as compared to conventional anticoagulant
locks alone. From that perspective, this approach seems
attractive. However, there are several concerns. First, an
aliquot of the intraluminal CVC lock solution invariably
leaks into the systemic circulation and may cause
toxicity. For example, concentrated gentamicin locks
resulted in ototoxicity in a subset of patients in 1
study.609
Similarly, 30% citrate may cause symptomatic
hypocalcemia, as manifested by paresthesia in 15% of
patients in 1 study.526
More importantly, the Work
Group committee members were concerned about the
potential of long-term prophylactic antibiotic locks
leading to antibiotic-resistant infections. There are
conflicting reports about the potential of prophylactic
gentamicin locks to select for infection with resistant
bacteria during prolonged use. Landry et al610
documented
this possibility, but 2 other large studies did not
observe such a complication.584,589
The considered use of antibiotic locks is limited to
high-risk patients as defined by the high-risk groups
studied in the trials reviewed by the ERT; that is, patients
with prior multiple CRBSI and S aureus nasal carriage;
other potential high-risk patients have not been
defined. The facility threshold for use of an intraluminal
prophylactic strategy has not been validated and was
discussed at length by the Work Group. The Work
Group came to a consensus of a baseline CRBSI rate
of ≥3.5/1,000 CVC days based on prior literature, potential
resource implications, and the finding that high
rates of CRBSI can and should be reduced first with
retraining and use of best CVC care practices and
infection control.579,592,611
Implementation Considerations
The potential concern about selection for antibioticresistant
infections makes the Work Group committee
reluctant to recommend antibiotic lock solutions across the
board. Thus, our recommendation is to use prophylactic
antibiotic locks in those scenarios where the benefit outweighs
the potential risk, namely, patients at high risk for
CRBSI or units with high rates of CRBSI. These would
include patients at high risk of CRSBI (eg, multiple prior
CRSBI and persistent, S aureus nasal carriers) or facilities
with high rates of CRBSI (eg, >3.5/1,000 days). Use of
nonantibiotic antimicrobial CVC solutions may be a superior
option, due to the low likelihood of selecting for
antibiotic-resistant infections.
The RCT using methylene blue highlighted that review,
retraining, and implementation of best CVC care
practices can achieve a low baseline CRBSI (0.8 episodes/1,000
CVC days),612
emphasizing that use of antibiotic
lock prophylaxis should be used only in facilities with very high
baseline risk of CRBSI even after the implementation of best CVC care
and infection control practices.
Future Research
 Determine and validate patients at high risk of CRBSI,
despite confirmed excellent CVC care and infection
control practices.
 Effect of risk stratification of patients at high risk of
CRBSI and their prophylactic management of CRBSI,
including strategies that involve extraluminal (eg, exit
site) and intraluminal antimicrobial prophylactic care.
 It is unclear whether prophylactic strategies should be
targeted to patients, facilities, or both at high risk of
CRBSI; considerations of the effect of widespread prophylactic
use of antibiotics and the potential emergence
of antibiotic-resistant organisms affecting not only the
Guideline 24: Prevention of CVC-Related Infection
S126 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
patient level but also the facility level must be considered
and rigorously studied.
Guideline 25. Treatment of CVC-Related Infection
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation”, the Work Group cannot make
any recommendation, suggestion or other evidence based guidance (in
either direction) based on the very low, low or inadequate quality of
evidence amassed by the ERT.
Statement: Management of the Patient With a CVCRelated
Infection
25.1 KDOQI considers it reasonable and necessary to
obtain appropriate cultures prior to initiating
empiric antibiotics for the treatment of suspected
CVC-related infection, with a change in antibiotics
according to culture sensitivities. (Expert
Opinion)
Note: See Rationale and Detailed Justification sections for further
detailed guidance.
Statement: Management of the CVC in a Patient
With a CVC-Related Infection
25.2 KDOQI considers it reasonable to have an individualized
approach to the management of an
infected catheter based on the patient’s health,
dialysis, and vascular access circumstances and
should follow the detailed guidance. Options
include CVC exchange via guidewire, CVC removal
and reinsertion, CVC salvage, and concurrent
antibiotic lock (particularly if the CVC is deemed
to be the patient’s final access). (Expert Opinion)
Note: See Rationale and Detailed Justification section for detailed
guidance.
Rationale and Detailed Justification
CVC-related infections and bacteremia are a significant
cause of morbidity and mortality for HD patients. CVCrelated
infections include exit site infections, infections
of the tunnel track, and bacteremia. Bacteremia is the most
significant complication because it has the potential to lead
to life-threatening sepsis and serious complications, such
as endocarditis. The common clinical features of CVC
infection include fever or chills, hemodynamic instability,
CVC dysfunction, hypothermia, nausea and vomiting, and
generalized malaise.572,613,614
Treatment of the 3 main
types of CVC-related infection—exit site infection, tunnel
infections, and CVC-related bacteremia—requires careful
consideration on how to (1) treat the patient and (2)
manage the CVC.
Please see Guideline 23 for definitions of CVC-related
infections. Treatment of each type of CVC-related infection
must consider local infection control practices and its
influence on organism patterns, cultures, and sensitivities.
Properly collected cultures must be obtained before initiating
empiric antibiotic treatment for all types of CVCrelated
infections to properly treat the infection and
avoid antibiotic resistance.
Exit Site Infections
If drainage is present from the exit site, cultures should
be obtained before initiation of antibiotics.572
If there
are signs or symptoms or other concern of systemic
infection, blood cultures should also be obtained.
Empiric antibiotic treatment should cover Gram-positive
organisms and be further modified once culture and
sensitivity results are finalized.572
Duration of treatment
for exit site infections typically range between 7 and 14
days.572
CVC management of exit site infections: This typically
does not require removal; however, this depends on the
infecting organism and the response to antibiotic therapy.
Tunnel Infections
When CVC tunnel infections are present, cultures from
drainage from the tunnel or exit site and blood cultures
from the CVC need to be obtained.572
After attainment of
the appropriate cultures, empiric antibiotics should be
initiated to target both Gram-positive and Gram-negative
organisms.572
Antibiotics should be modified once culture
and sensitivity results are available. The typical treatment
duration for CVC tunnel infections is 10 to 14 days
in the absence of concurrent bacteremia.572
If CVC-related
bacteremia is also present, the duration of treatment
should be dictated by the management strategy for the
CVC-related bacteremia.572
CVC management of tunnel infections: If the tunnel
infection is not effectively treated with antibiotics,
consider CVC exchange with a new subcutaneous tunnel to
preserve the venous access site.615
If not possible, the CVC
should be removed and a new CVC placed at a new entry
site.572
CRSBI or Bacteremia
Patients with suspected CRBSI should have blood cultures
obtained from the CVC and peripheral source (dialysis
circuit ± peripheral veins; Guideline 23). Broad-spectrum
antibiotics that treat both Gram-positive and Gramnegative
organisms should be initiated immediately.572
Due to the high prevalence of methicillin-resistant S
aureus, empiric therapy should include coverage for
methicillin-resistant S aureus318
but should also be guided
by the local infection rates, antibiotic sensitivities, and
dialysis center policies. Once the final organism and sensitivities
are identified, patients should receive long-term
antibiotic treatment, according to the CDC or IDSA
guidelines, for 4 to 6 weeks for uncomplicated S aureus, 7 to
Guideline 25. Treatment of CVC-Related Infection
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S127
14 days for Gram-negative bacilli or enterococcus, and a
minimum of 14 days with Candida species319
(Fig 25.1).
CVC management of CRBSI: There are 4 main options
that involve removing the CVC or retaining the CVC, as
follows:
Removing the CVC:
1. CVC removal with CVC exchange over a guidewire at
the same site
2. CVC removal with new CVC replaced at a new site
(± “CVC free” duration [whereby the patient has a
period when there is no CVC in-situ] with insertion of a
temporary CVC as needed for dialysis).
Several situations necessitate the latter option of immediate
CVC removal with delayed CVC
placement318,572
:
a. Clinically and hemodynamically unstable patients
b. Persistent fever 48 to 72 after initiation of systemic
antibiotics
c. Persistent bacteremia 48 to 72 hours after initiating
antibiotics
d. Metastatic complications, including suppurative
thrombophlebitis, endocarditis
e. Infections due to S aureus, Pseudomonas aeruginosa, fungi,
or mycobacteria
f. Presence of a tunnel-site infection616
Note: In uncuffed, temporary CVC, CRBSI due to Gram-negative
bacilli, S aureus, enterococci, fungi, and mycobacteria warrant
CVC removal.
At the time of CVC removal, evaluation for the presence
of fibrin sheath (presumably with infected biofilm) and
fibrin sheath disruption can be performed (Guideline
Statement 26.3).
Retaining the CVC:
1. Retain CVC and use antibiotic CVC lock
2. Retain CVC without use of antibiotic CVC lock
Antibiotic locks with concurrent systemic antibiotics
may be an alternative treatment strategy to preserve the
CVC. Although there are no RCTs evaluating the role of
antibiotic CVC locks in the treatment of CRBSI, there have
been several observational studies demonstrating eradication
of bacteremia with antibiotic locks in conjunction
with systemic antibiotics compared to CVC exchange or
removal in conjunction with systemic
antibiotics.572,617,618
Although the best management of CVC-related infections
is to avoid them altogether, it is very unlikely that
CVC can be completely eliminated, because 80% of patients
initiate HD with a CVC.516
Thus, there are several
core interventions recommended by the CDC that KDOQI
• Check defini ons of CVC-related infec on (Tables 23.1 and 23.2)
• Rule out possible non–CVC-related infec ons (eg, diabe c foot or pneumonia)
Pa ent Hemodynamically UNSTABLE Pa ent Hemodynamically STABLE
Consider appropriate treatment strategy (below)
• Blood cultures x 2: 1 is obtained from the CVC hub and 1 is obtained from the circuit (Table 23.1)
• Blood cultures should be obtained before star ng an bio cs
• Start empirical an bio cs
• Check INR, per local requirements for possible CVC removal
ABC’s, stabilize, consider ICU
Nega ve blood cultures Resolu on of bacteremia/fungemia and fever in 2-3 days Persistent bacteremia/fungemia and fever
Look for persistent cause, eg, infected fibrin sheath
• An bio c or an fungal x 4-6 weeks,
as directed by culture results
• Remove CVC
• Guidewire exchange*
• Remove fibrin sheath if present and
appropriate
• Look for metasta c infec ons
Stop an bio cs Gram-nega ve
bacilli
Staphylococcus aureus Candida species Arrange for urgent CVC removal
Guidewire exchange*
Coagulase-nega ve
staphylococcus
• An bio cs x 14 days
• Guidewire exchange*
• Remove CVC
• An bio cs x 4 weeks
• Guidewire exchange*
• Strongly consider TEE and look for
metasta c infec ons
• Remove CVC
• An fungal x 14 days
• Guidewire exchange*
• Look for metasta c infec ons
Contact hemodialysis vascular access infec on control leader/coordinator or
other appropriate staff and team to monitor and facilitate treatment
Figure 25.1. Algorithm for CVC-related infection. Special consideration: if the CVC must be salvaged (eg, no other option, embedded, etc), antibiotic
lock with concurrent systemic antibiotic may be considered.*If appropriate—that is, no purulence or other signs of infection at exit site or tunnel
if exchanging over same site. For tunnel infections, if there is purulence or other signs of infection at exit site or tunnel, exchange may be possible over
new noninvolved insertion site using the same side to preserve access. Abbreviation: CVC, central venous catheter.
Guideline 25. Treatment of CVC-Related Infection
S128 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
endorses that can be useful to decrease infection rates and
complications in patients requiring dialysis with a CVC,
and these are covered in Guidelines 24 and 25. These core
interventions include572
(1) infection surveillance and
feedback, (2) strictly following proper hand hygiene
practices, (3) strictly following proper CVC/vascular access
care protocols, (4) staff education and competency,
(5) patient education and engagement, (6) CVC reduction
efforts, (7) chlorohexidine for skin antisepsis, (8) CVC
hub disinfection, and (9) antimicrobial ointment.
Multidisciplinary team surveillance and management of
CVC-related infections has been demonstrated to reduce
infections and improve outcomes in hemodialysis patients
who require a CVC for dialysis access.309,324
Future Research
 Clinical sequelae of disrupting a fibrin sheath in patients
with CRBSI requires further study.
 Prospective studies comparing treatment of CRBSI using
antibiotic locks in conjunction with systemic antibiotics
versus CVC exchange or removal in conjunction with
systemic antibiotics is needed.
Guideline 26. Other Vascular Access-Related
Complications
Please refer to Box 1 to understand the evidence basis for
the Guideline Statements.
Note: When a statement indicates that “There is inadequate evidence
for KDOQI to make a recommendation,” the Work Group cannot make
any recommendation, suggestion, or other evidence-based guidance (in
either direction) based on the very low, low, or inadequate quality of
evidence amassed by the ERT.
Statement: Treatment and Intervention of
Asymptomatic Central Venous Stenosis Without
Clinical Indicators
26.1 KDOQI considers it reasonable that if asymptomatic
central venous stenosis (without clinical indicators)
is identified and/or associated with
the prior or current presence of a CVC, it should
not be treated. (Expert Opinion)
See Table 26.1 for clinical indicators of central venous stenosis.
Rationale/Background
Stenoses or occlusions in the major intrathoracic veins (ie,
central veins—internal jugular, subclavian, brachiocephalic,
superior vena cava) can compromise AV access
function and lead to ineffective dialysis. These lesions can
also lead to marked venous hypertension due to the
increased flow associated with the AVF with sequelae
ranging from mild to severe symptoms (ie, positive clinical
indicators) as characterized by varicosities, arm edema,
dermatosclerosis, ulceration, and superior vena cava syndrome
(Table 26.1 and Fig 26.1). Female patients can
occasionally present with ipsilateral breast edema despite a
normal or only moderately swollen extremity. These stenotic
lesions can lead to clinical signs and symptoms such
as prolonged bleeding after removal of the dialysis cannulas
and/or elevated venous pressures during routine
monitoring with high AV access recirculation. Central vein
stenoses (CVS) or occlusions have been reported to occur
in up to 5% to 50% of cases237,619-622
and represent the
Achilles heel of maintaining or creating a functional AV
access. They can preclude the placement of an ipsilateral
AV access and likely account for the leading etiology of
complex or tertiary AV access problems.
The central vein lesions are likely caused by an initial
injury to the vascular endothelium that precipitates a local
Table 26.1. Signs and Symptoms (Clinical Indicators) of Central Venous
Stenosis
Timing of
Occurrence Sign or Symptom Comments
Early signs and
symptoms
Swelling Typically asymmetric, affecting
the hands and arms
Pain Pain that can be attributed to
central venous stenosis/
occlusion, such as aching and
heaviness of an extremity, when
other causes have been
excluded
Cutaneous
findings
Venous collaterals
Skin discoloration (red, purple, or
blue discoloration)
Late signs and
symptoms
Swelling More widespread, affecting the
arms, head, neck, or trunk
(including breasts)
Swelling may be unilateral,
bilateral, or involve only the head,
face, and neck.
Pain Persistent pain attributed to
central venous stenosis/
occlusion (eg, persistent aching,
chest or extremity heaviness)
Cutaneous
findings
Venous collaterals
Skin discoloration (red, purple, or
blue discoloration; chronic
pigmentation changes)
Lymphatic blistering or weeping
Stasis ulcers
Phlebitis
Infection (cellulitis, cannulation
site abscess)
Nonhealing wounds or incisions
Respiratory
compromise
Hoarse voice and/or respiratory
distress from laryngeal edema,
pleural effusion, or chest (or
breast) swelling that can cause
restrictive pulmonary
compromise
Neurologic
symptoms
Visual or auditory disturbances,
exophthalmos, cognitive
disabilities, headaches, or
seizures when other causes have
been excluded
Guideline 26. Other Vascular Access-Related Complications
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S129
inflammatory response that leads to fibrosis. A variety of
factors have been shown to compound or exacerbate the
various steps of this process, including deep venous
thromboses, intravascular CVC, cardiac rhythm devices
(eg, pacemakers), and HD AV accesses themselves.
Peripherally inserted central catheters (ie, PICCs) have
been reported to cause a CVS or occlusion in up to 7% of
cases, whereas subclavian catheters have been reported to
cause these lesions in up to 50% of cases.266
Even appropriately
positioned (ie, internal jugular inserted) CVCs can
lead to CVS and/or occlusions within a relatively brief
period of time. The true incidence of CVC-induced CVS/
occlusion is unknown. If CVS is incidentally identified on
angiographic assessment without clinical symptoms, it is
unknown what the natural history of the stenosis is over
time. However, overall, CVS/occlusions may represent the
worst of the CVC-related complications, underscoring the
importance of limiting their use.
Indeed, angioplasty for asymptomatic stenosis is associated
with a more rapid progression to symptomatic
stenosis623,624
and should therefore be avoided unless
there is a clinical indication to perform an angioplasty. In
patients with symptomatic CVS/occlusion, primary
patency with angioplasty or angioplasty with stenting is
very poor.2
Although stent grafts have demonstrated
improved patency in peripheral stenosis, outcomes for
central lesions are uncertain based on small retrospective
studies.
The current Guidelines differ from prior KDOQI
guidelines as they recommended treatment of CVS with
PTA but without clarity regarding whether clinical symptoms
were also present as an indication for intervention.
Stent placement was recommended for (1) acute elastic
recoil of >50% or (2) stenosis recurrence within 3 months.
Elastic recoil itself has been poorly defined.
Detailed Justification
In 2 retrospective studies that assessed central vein patency
in patients with asymptomatic versus symptomatic CVS,
both studies recommended against intervention for
asymptomatic stenosis. The first study excluded patients
with CVCs but found that treatment of asymptomatic CVS
greater than 50% in the setting of HD access maintenance
procedures was associated with more rapid stenosis progression
and escalation of lesions, compared with a
nontreatment approach.623
In the second study, primary
central vein patency at 12, 24, and 36 months in
asymptomatic/pauci-symptomatic patients and symptomatic
patients with CVS were 77% ± 6% versus 55% ± 9%,
71% ± 7% versus 35% ± 9%, and 67% ± 7% versus 18% ±
9%, respectively (P = 0.002).624
Angioplasty and/or angioplasty and stenting for CVS
are associated with relatively poor patency. In 1 retrospective
study, primary patency of 76% was equivalent
for angioplasty or angioplasty with stenting at 30 days,
with 12-month rates of 29% for angioplasty and 21% for
stenting.2
However, in another retrospective study in HD
patients without CVCs, primary patency (time from
intervention to next intervention) was 24.5 months in
the angioplasty group and 13.4 months in the stent
group.625
Special Discussions
The Work Group discussed the signs and symptoms that
may require confirmatory diagnosis and intervention,
including
 Ipsilateral facial, neck, breast or extremity swelling
(without other cause)
 Repeated thrombosis of an upper arm access in the
absence of other causes within 6 months
 Pain in the extremity related to venous obstruction
 Neurologic symptoms in the absence of other etiologies
 Venous pressure is highly variable and dependent on
many patient and HD factors and their interactions.
Therefore, intervention should not be based solely on
venous pressure, but other signs and symptoms should
be present as well.
Figure 26.1. Physical findings of central venous stenosis. (A) Venous collaterals evident on the chest and neck. (B) Asymmetric extremities due to
venous congestion and arm swelling from central venous stenosis.
Guideline 26. Other Vascular Access-Related Complications
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Future Research
 Understanding the natural history of CVS
 Prospective studies on intervention of symptomatic CVS
Statement: Investigation and Treatment of
Symptomatic Central Venous Stenosis With Clinical
Indicators
26.2 Same as guidelines for “AV Access Flow Dysfunction–Confirmation
And Treatment”
See Guideline 15. See Table 26.1 for clinical indicators of central
venous stenosis.
Rationale/Background
As discussed for asymptomatic central venous stenosis.
Detailed Justification
Close routine clinical monitoring will detect signs and
symptoms suggestive of clinically significant CVS and
venous hypertension (Guidelines 11 and 13). The culprit
lesion can usually be confirmed with catheter-based and
CT venography, given the limitations of ultrasound in the
thoracic cavity. CT venography offers the advantage of
being noninvasive and the potential to image all 4 extremities
at the same time, although the timing of the
contrast injection and image acquisition can be
challenging.
Patients with mild symptoms can improve over time
with the development of collaterals, and it is not uncommon
to see patients with a functional AV access and no arm
edema despite a CVS/occlusion.626
Intervention is not
indicated for asymptomatic lesions or those associated
with minimal symptoms624
(Guideline 13).
The treatment indications for CVS/occlusions include
persistent moderate/severe clinical signs and symptoms
(Guideline 13) and/or related ineffective dialysis. It is
relatively common for patients to develop some arm
edema after AV access construction, likely related to the
operative trauma and mild venous hypertension. This
usually resolves in the first 2 to 6 weeks postoperatively
with the resolution of the inflammation from the surgical
trauma and the development of venous collaterals.
The endovascular approach with balloon angioplasty is
the first line of treatment for these symptomatic CVS/occlusions.
Intraluminal stenting is reserved for angioplasty
failures. Although the early technical success rates for the
endovascular treatment are excellent and can exceed
90%,266
the longer-term 6- and 12-month primary patency
is poor, at 50% and 25%, respectively.627-629
Notably, Yan
et al630
reported that balloon angioplasty of the central vein
lesions had little impact on the AV access flow, although it
was effective in relieving the symptoms. Intraluminal
stenting should be reserved for recurrent stenosis, given the
uncertainty of outcomes.266,629
Indeed, stents should be
used with caution (or avoided altogether) in the region of
the thoracic outlet due to the potential for extrinsic
compression and stent fracture from the overlying structures.
Placing stents over pacer wires can complicate their
removal. Thus, pacer wires can be removed (and the pacer
re-sited) prior to the placement of an intraluminal stent;
however, it may be simpler to create another AV access on
the contralateral extremity (if possible), particularly given
that the sclerotic lesions associated with the pacer wires tend
to be refractory to balloon angioplasty.
Covered stents afford some theoretical appeal because
the intimal hyperplasia does not develop within the
covered segment, although it can develop at the proximal
and distal ends of the stent. Furthermore, the covered
component of the stent can inadvertently cover or “jail”
important collaterals or the major central veins (eg, internal
jugular). Caution must be exercised when using
intraluminal stents. A careful tiered approach for de novo
and recurrent lesions progressing from balloon angioplasty
to bare metal stents followed by covered stents should be
considered in the context of the patient’s Life-Plan and the
vascular access contingency and successions plans.629
There are a variety of open surgical options for patients
with CVS/occlusions associated with their vascular access.
However, these are considered secondary or tertiary options
and are largely dictated by the anatomy in terms of available
patent inflow and outflow veins. Potential options including
axillary-jugular bypass, axillary-axillary bypass, axillaryfemoral
bypass, axillary-atrial bypass, or the jugular vein
turndown procedure.631,632
Alternatively, associated
venous hypertension may be reduced by limiting the flow
through the AV access by using some variant of a banding or
flow-limiting procedure (Guideline 18).
The Hemoaccess Reliable Outflow (HeRO) Vascular
Access Device (Hemosphere, Inc) can be used as a hybrid
alternative (ie, combination endovascular/open surgical
approach) access once the occlusion is bypassed.633
The
HeRO graft is a 6 mm (inner diameter) PTFE graft that is
coupled to a 19 Fr (outer diameter) CVC. Although typically
used as a new AV access configuration, the HeRO
graft can be used in combination with an existing AVF or
AVG to provide the “central vein runoff,” provided that
the delivery sheath for the CVC can be passed through the
lesion.633,634
Statement: Management of CVC Fibrin Sheath
Associated With Clinical Problems
26.3 KDOQI considers it reasonable that when a CVC
fibrin sheath is associated with adverse clinical
manifestations (CVC dysfunction and/or infection),
a CVC exchange with or without balloon
disruption of the fibrin sheath should be performed.
(Expert Opinion)
Guideline 26. Other Vascular Access-Related Complications
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Rationale/Background
Fibrin sheaths are a known cause of CVC dysfunction and
infection that cannot be treated with thrombolytic therapy
alone. CVC exchange alone or exchange with balloon
disruption likely results in disruption of the fibrin
sheath.635,636
The fibrin sheath is composed of smooth
muscle cells and vascularized connective tissue that originates
at the venotomy site and grows along the CVC.561,637
Once growth extends to the tip of the CVC, the sheath acts
as a valve, interrupting aspiration of blood from the CVC
but not return of blood through the CVC. Because
thrombolytics dissolve acute clot (<14 days) and not tissue,
they are ineffective against fibrin sheaths. Also, fibrin
sheaths can harbor bacteria. A prior typical management
strategy for suspected CRBSI is to remove the CVC, wait 48
to 72 hours, and reinsert a new CVC. The presence of an
infected fibrin sheath and its consequences was often not
considered in the setting of CRBSI. Disrupting the fibrin
sheath may eliminate CRBSI and has been shown not to
increase bacteremia rates564
; thus, its disruption may assist
in eliminating a source of recurrent infection.
The prior 2006 KDOQI guideline stated that a fibrin
sheath causing CVC malfunction can be treated with CVC
exchange with or without balloon disruption. No statement
was made in the prior guidelines regarding disrupting
fibrin sheaths to prevent or treat bacteremia.
Detailed Justification
In a randomized prospective pilot study, 47 long-term HD
patients with secondary, refractory CVC dysfunction underwent
guidewire exchange to replace their CVCs. Fibrin
sheaths were present in 33 (70%) of the 47 patients. In 18
patients who were randomly assigned to disruption, the
median time to repeat dysfunction was 373 days compared
with 97.5 days in patients who did not undergo disruption
(P = 0.22), and the median time to repeat CVC exchange
was 411 and 198 days, respectively (P = 0.17). Although
significance was not obtained due to the small sample size,
the study highlighted a high incidence of fibrin sheaths
and a trend toward improved function with balloon
disruption.560
Another study found the incidence of fibrin
sheath formation for dysfunctional CVCs to be 76%.638
In an animal study assessing whether fibrin sheath
presence results in increased CVC-related infection and
persistent bacteremia, the fibrin sheath group exhibited a
50% infection rate versus 0% in the no fibrin group (P <
0.01).639
There is no comparable published study in
humans.
Special Discussions
There is very limited literature on fibrin sheaths and their
impact in HD patients. The current data are comprised of
small series, mostly retrospective in nature. Thoughts
regarding bacteremia are anecdotal. The Work Group acknowledges
that our suggestion of considering balloon
disruption is based on limited data.
Implementation Considerations
Clinicians should carefully consider and balance an increase
in intervention rate and potential complications
with balloon angioplasty compared with simple CVC
exchange.
Future Research
 RCTs comparing thrombolytics versus catheter exchange
versus catheter exchange with fibrin sheath
disruption would be highly beneficial and needed
 The associations of fibrin sheath incidence with CRBSI
and impact of disruption and antibiotics versus antibiotics
alone on CVC malfunction and infection are
important to investigate and define
Guideline 26. Other Vascular Access-Related Complications
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KDOQI VASCULAR ACCESS GUIDELINES GOALS AND TARGETS
Targets are clinical metrics or thresholds that can be used
in tracking provider performance measurement.
Overarching Goal: to achieve reliable, functioning,
complication-free dialysis access to provide prescribed
dialysis while preserving future dialysis access site options
as required by the individual patient’s ESKD Life-
Plan.
Rationale for Targets
1. Establish and Document the Patient’s P-L-A-N
The concept and rationale for the ESKD Life-Plan is detailed
in Guideline 1. A template example is given in Supplement
2. The ESKD Life-Plan should be determined with the
patient and interdisciplinary team and reviewed on an
annual basis. Such an approach is consistent with Centers
for Medicare & Medicaid Services conditions of coverage
Patient Assessment ruling 494.80 and Patient Plan of Care
494.90. Section 494.80 states that a facility’s interdisciplinary
team is responsible for providing each patient with
an individualized and comprehensive patient assessment of
his or her needs. Section 494.90(a) states that a facility’s
interdisciplinary team must develop and implement a written, individualized
comprehensive plan of care that meets all of the
requirements of x494.90. The comprehensive plan must
be documented and maintained in the patient’s record.
In particular, subsections 8 and 9 of condition 494.80
indicate that the following should be specifically done,
consistent with the philosophy of these guidelines of
obtaining “the right access, in the right patient, at the right
time, for the right reasons” by using an individualized P-LA-N,
as follows:
(9) Evaluation of the patient’s abilities, interests, preferences,
and goals, including the desired level of
participation in the dialysis care process; the
preferred modality (hemodialysis or peritoneal
dialysis), and setting, (for example, home dialysis),
and the patient’s expectations for care outcomes.
(8) Evaluation of dialysis access type and maintenance
(for example, arteriovenous fistulas, arteriovenous
grafts, and peritoneal catheters).
Furthermore, subsection 5 of condition 494.80 indicates
the following:
(5) Vascular access. The interdisciplinary team must provide
vascular access monitoring and appropriate,
timely referrals to achieve and sustain vascular access.
KDOQI Vascular Access Guidelines Goals and Targets
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S133
The hemodialysis patient must be evaluated for the
appropriate vascular access type, taking into consideration
co-morbid conditions, other risk factors, and
whether the patient is a potential candidate for AVF
placement. The patient’s vascular access must be
monitored to prevent access failure, including
monitoring of AVG and AVF for symptoms of
stenosis.
In terms of implementing the ESKD Life-Plan, the
conditions of coverage stipulate the following:
Standard: Implementation of the patient plan of care.
(1) The patient’s plan of care must—
(i) Be completed by the interdisciplinary team,
including the patient if the patient desires; and
(ii) Be signed by team members, including the patient
or the patient’s designee; or, if the patient chooses
not to sign the plan of care, this choice must be
documented on the plan of care, along with the
reason the signature was not provided.
These specifications in the Centers for Medicare &
Medicaid Services conditions of coverage are in alignment
with the current 2019 KDOQI guideline.
2. Intervention Goal for AV Access
AV access interventions are often necessary to facilitate an
AV access for it to be usable for dialysis and/or to maintain
its patency and use. However, unnecessary interventions
can lead to reductions in patient quality (eg, discomfort/
pain, inconvenience) and increased costs to the health care
system. Currently, there is no guidance regarding intervention
thresholds over which a patient and care team
should consider alternate vascular access options, but this
should be included as part of the vascular access contingency
plan (ie, how many interventions should a patient
tolerate before abandoning the current AV access). The
only exception to limiting repeated interventions beyond
the suggested thresholds is if the AV access is the patient’s
“destination” vascular access (ie, no other AV access options
are feasible), and heroic attempts may be required to
continue its prolonged use.
The thresholds for interventions to facilitate and
maintain AV access use are based on available data from the
current literature (Box 3). Furthermore, greater interventions
to either facilitate or maintain an AVF have not
demonstrated superior survival compared with AV accesses
with fewer interventions.640,641
3. CRBSI Goal for Central Venous Catheters
The 2 most significant complications of CVC use are CVC
dysfunction (Guidelines 21 and 22) and CVC-related
infection, especially CRBSI (Guidelines 23-25). Although
CVC dysfunction may be frequently inconveniencing to
the patient due to necessary medical or interventional
treatment, it is infrequently life threatening. On the other
hand, CRBSI pose significant risks to patient morbidity and
mortality. Although the 2019 KDOQI guideline’s P-L-A-N
permits an individualized approach to vascular access
choice and use of CVC under specific circumstances, it is
critical that, should a CVC be the appropriate vascular access
for a patient, processes are followed to limit the risk of
CVC related infections, particularly CRBSI (Guidelines 11,
21, 24, and 25). Evidence clearly demonstrates that
prophylactic measures can significantly reduce CVC
infection rates, and national data demonstrates that a target
CRBSI rate of 1.5 or fewer infections/1,000 CVC days is
possible.
Such data are derived from a national database,
CROWNWEB, which is reported to the National Healthcare
Safety Network. Each dialysis facility tracks HD-related
bloodstream infections that are submitted on a monthly
basis, reviewed by the National Healthcare Safety Network
and CDC (CDC is the measure steward), and reported via
the National Quality Forum. The most updated report
(National Quality Forum #1460) on bloodstream infections
(BSI) in HD units reported “in facilities all using a
uniform method of measuring and reporting BSI has
facility-specific rates that ranges 0-30.8 BSI per 100-patient
years,” which is equivalent to 0.84/1,000 CVC days. The
pooled mean BSI for CVC among facilities reporting was
4.2 per 100 patient months, equivalent to 1.38/1,000
CVC days. Thus, a targeted rate of <1.5/1,000 CVC days is
reasonable. Prophylactic measures have been demonstrated
to have risk reductions for CRBSI of 22% to 60%
(Guideline 24),524,642,643
and should be used to achieve
this target.
Comparison to 2006 KDOQI Guideline Targets
Due to changes in patient demographics and practice
patterns, many of the prior 2006 KDOQI guideline targets
are no longer clinically relevant and require re-evaluation,
or the targets have been achieved or have become standard
of care (eg, establishing a continuous quality improvement
process). Over the past decade, we have gained great
insight due to clinical experiences and research. For
example, we now know that targeting thrombosis for AVFs
does not result in improvement in AV access survival/
longevity and that intervention may be counterproductive.
Understanding the role of patient, vessel, and surgical
factors for superior AV access survival and assessing the
patient for eligibility for different AV access types and what
is “right” for that individual patient is a priority in these
guidelines.
The Overarching Goal is to provide functional,
complication-free dialysis access while preserving future
dialysis access site options as required by the individual
patient’s ESKD Life-Plan. Hence, the current targets differ
from the prior guidelines in focusing on the major components
that might interfere with achieving this overarching
goal, and by doing so, also encompass many of the
prior guideline targets.
KDOQI Vascular Access Guidelines Goals and Targets
S134 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Box 3. Interventions
First Author
Type of Study, Number
of Patients, and Type of
AV Access
Duration of
Follow-Up
Number of
Interventions Rate Comments
AV Fistulas: Interventions to Facilitate Maturation or Use (BEFORE First Cannulation)
Yang, 2017644
Retrospective, observational,
case-controlled
SAVF: n = 60
EAVF: n = 60
SAVF: 183 d (6 mo)
EAVF: 319 d (11 mo)
SAVF: 6 mo
EAVF: 6 mo
Unknown SAVF: 3.43/patient-year
EAVF: 0.59/patient-year
SAVF: 3.43/patient-year
EAVF: 0.78/patient-year
CMS Data 2011-2013 (SAVF
cohort)
NEAT Study (EAVF cohort)
Facilitative and maintenance
procedure, so cohorts include
CKD non-HD and prevalent
HD patients
Kimball, 2011645
Retrospective chart review
AVF: n = 150
Upper arm: 54%
Lower arm: 46%
12 mo
Median: 10 mo
Unknown Mean number: 2
interventions/AVF
(range, 1-10)
On HD using AVF (n = 48)
Not on HD patent AVF (n = 34)
On HD failed AVF (n = 26)
Not on HD failed AVF (n = 42)
Interventions are facilitative and
maintenance
Falk, 2006646
Retrospective
AVF: n = 154
IAVF: n = 65
Unknown 113 in 65
immature AVFs
1.7 interventions/IAVF
Shenoy, 2005647
Retrospective
AVF: n = 398
cAVF: n = 199
sAVF: n = 199
Unknown 53 cAVF: 0.22
interventions/AVF-year
sAVF: 0.37
interventions/AVF-year
Accesses placed between
1996 and 1999
Does not specify facilitative or
maintenance procedures
Perera, 2004648
Retrospective
AVF: n = 100
3 y 51 0.53 interventions/
patient/y
Facilitative and maintenance
procedures included
AV Fistulas: Interventions to Maintain Function/Patency (AFTER Successful Cannulation and Established Use)
Harms, 201673
Retrospective
Prospective data base
AVF: n = 289
NIAVF: n = 143
IAVF: n = 146
AVF: 6.5 y
Mean follow-up:
2.3 y
Unknown All AVF: 0.63 interventions/y
NIAVF: 0.46 interventions/y
IAVF: 0.84 interventions/y
50.5% of AVFs needed intervention
before HD
Lee, 2011287
Retrospective
Prospective data bases
AVF: n = 173
Median: 672 d Unknown 0IAVF(96): 0.76 interventions/y
1IAVF(54): 1.37 interventions/y
2IAVF(23): 3.51 interventions/y
Database UC and UAB 2005-2007
Follow-up from time of cannulation,
so only maintenance procedures
Of 173 patients, 77 needed
facilitative interventions
Falk, 2006646
Retrospective
AVF: n = 154
MAVF: n = 63
Mean: 317 d 209 3.3 interventions/AVF
1.75 interventions/AVF-year
—
Manns, 2005344
Prospective
AVF: n = 157
12 mo Unknown AVF surgery: 1.39/PY
AVF angiogram: 0.81/PY
AVF angioplasty” 0.43/PY
Data from Southern Alberta
Transplant Program Database
(ALTRAbase)
AV Grafts: Interventions to Facilitate Maturation or Use (BEFORE First Cannulation)
Shenoy, 2005647
Retrospective
AVG: n = 745 cAVG: n = 401
sAVG: n = 344
—
635
cAVG: 0.86/AVG-year
sAVG: 1.73/AVG-year
Accesses placed between 1998 and 1999
Does not specify facilitative or maintenance
AV Grafts: Interventions to Maintain Function/Patency (AFTER Successful Cannulation and Established Use)
Harms, 201673
Retrospective
Prospective data base
AVG: n = 310
AVG: 6.5 y
Mean follow-up:
2.01 y
Unknown All AVG: 1.58 interventions/y
No intervention AVG: 1.48 interventions/y
Intervention AVG: 2.2 interventions/y
17.7% AVGs needed
intervention before HD
(Continued)
KDOQI Vascular Access Guidelines Goals and Targets
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S135
Box 3 (Cont'd). Interventions
AV Grafts: Interventions to Maintain Function/Patency (AFTER Successful Cannulation and Established Use)
Manns, 2005344
Prospective
AVG: n = 33
12 mo Unknown AVG surgery: 1.70/PY
AVG angiogram: 1.33/PY
AVG angioplasty: 0.94/PY
Data from Southern Alberta
Transplant Program Database
(ALTRAbase)
Perera, 2004648
Retrospective
AVG: n = 131
3 y 170 0.92 interventions/patient/y Facilitative and maintenance
procedures included
Abbreviations: AV, arteriovenous; AVF, arteriovenous fistula; AVG, arteriovenous graft; cAVF, clip arteriovenous fistula; EAVF, endovascular arteriovenous
fistula; IAVF, arteriovenous fistula with intervention for maturation; MAVF, mature arteriovenous fistula; NIAVF, no-intervention arteriovenous
fistula; PY, patient-year; sAVF, suture arteriovenous fistula; SAVF, surgical arteriovenous fistula.
KDOQI Vascular Access Guidelines Goals and Targets
S136 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
RESEARCH RECOMMENDATIONS
Future Research for Hemodialysis Vascular
Access and Related Topics
Effective and appropriate application of the individualized
ESKD Life-Plan strategy described in this Guideline requires
a broader perspective than focusing solely on the creation
of a specific vascular access or the monitoring and management
of an existing vascular access. The Life-Plan
approach requires consideration of the patient’s current
and future goals and preferences, as well as his/her current
and future medical condition(s). To appropriately consider
all of these aspects will require additional knowledge on
patient preferences, more accurate tools to predict the
timing of the need for dialysis, and better data on the
expected outcomes associated with various approaches to
dialysis access creation and preservation. To truly individualize
the choices, each of these research areas will need
to address potential differences across patient subgroups to
allow evidence-based decision making for specific patients.
Timing of the Need for Dialysis
Planning for initial dialysis access in CKD requires some
knowledge of the urgency of the need for dialysis. The
Work Group agrees that assessment for vascular access
should occur if the patient has a ≥50% risk of needing KRT
within 2 years and/or has an eGFR of ≤15 mL/min/
1.73m2
; however, this is based on Expert Opinion only.
Tools to predict risk of ESKD, using eGFR and/or other
commonly obtained variables, have been developed
recently,649-652
including the 4-variable Kidney Failure
Risk Index.653
The current limited evidence supporting the
validity of these prediction tools is based on a single
evaluation of each participant’s status, which may change
quickly. Future studies will require repeated assessments to
determine whether a patient has crossed a threshold where
dialysis access evaluation or creation is deemed appropriate.
Only recently has a dynamic prediction tool been
published.652
Although this tool uses updated information,
it does not take full advantage of the patient’s history and
previous experiences.
Numerous prediction tools have been developed, but
few have been validated in other populations, and even
fewer have been subjected to an evaluation of their
impact.654
The impact of utilizing a risk prediction tool
and associated practices on vascular access specifically has,
to our knowledge, not been evaluated for any specific tool.
Much work remains in how best to implement vascular
access–related clinical decisions based on the projected
probability of kidney failure for a specified time horizon or
the estimated time to kidney failure. Again, the best
approach may differ based on a specific patient’s characteristics
and preferences, which must be addressed in these
evaluation studies.
The other piece of the puzzle for optimizing the
timing of vascular access creation, of course, is the
time required from creation to use. Additional research
is needed on appropriate time for cannulation and how
to objectively and reliably determine readiness for
cannulation in traditional and newer vascular access
types, and methods to aid in AV access maturation.
Expected Outcomes Associated With Various
Approaches to Vascular Access Creation and
Preservation
National programs, including the Centers for Medicare
and Medicaid Services’s breakthrough initiative, Fistula
First, have aggressively campaigned for greater use of
AVFs and set goals of at least 66% AVF use and less than
10% CVC use among prevalent HD patients.655
Despite
these efforts, more than 80% of ESKD patients initiate HD
with a NT-CVC or CVC, and CVC use remains common
among prevalent HD patients.44,139
Numerous studies
have raised serious questions about this one-size-fits-all
approach to vascular access, finding substantial heterogeneity
across patients in the benefit derived from immediate
AVF creation.656-658
The Work Group
hypothesizes that a more patient-specific approach will
result in more appropriate vascular access choices.20,659
Multiple factors must be considered to apply the ESKD
Life-Plan strategy to vascular access creation decision
making, including the urgency of the need for a functioning
AV access versus the expected time required for
maturation; the infection risk associated with CVC use
during maturation versus the expected long-term benefit
of an AV access; the probability of maturation failure of an
AVF versus the potential long-term benefit over an AVG;
the patient burden associated with the planning, creation,
and complications associated with each vascular access;
and the potential need for future vascular accesses.
Although data exist to provide useful estimates based on
patient characteristics for some of these, such as predicting
the probability of maturation,660
there remain significant
gaps in our knowledge. Additional research is needed to
provide estimates for each of these variables across various
patient and vessel characteristics to inform patientcentered,
evidence-based decision making algorithms.
In the meantime, KDOQI has provided an app (www.
myvascularaccess.com) that can be used to facilitate dialysis
access decision making, based on evidence gained
through the UCLA RAND Appropriateness Method. This
tool requires further validation and research into the
impact on its implementation. It is important to emphasize
that it is only one tool, amongst others to assist with
getting “the right access in the right patient, at the right
time, for the right reasons”. A multidisciplinary approach
that involves the patient and family members/supporters
to fully understand and evaluate the patient for the ESKD
Life-Plan and dialysis access is central to achieving the
overarching goal.
Research Recommendations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S137
Patient Preferences
In addition to the clinical outcomes associated with
choosing any specific vascular access, numerous studies
have found that vascular access is a major concern of patients
faced with ESKD.661-663
Issues such as physical
disfigurement from an AVF and the pain and fear of needle
cannulation are of great concern to patients, but these have
been overlooked by initiatives such as Fistula First.664
Research has uncovered substantial heterogeneity in utilities
assigned to various factors across patients by age, sex,
and country.661
Additional research is recommended to
identify characteristics about processes and health outcomes
associated with vascular access that are most relevant
to patients’ decisions.
Specific Research Recommendations Pertaining
to Individual Guidelines
Please also see the accompanying list of topics of Potential
Future Research for Hemodialysis Vascular Access and
Related Topics under each Guideline topic.
ESKD Life-Plan Strategy
The overall impact of the ESKD Life-Plan Strategy must be
critically evaluated. This evaluation should include measures
of patient satisfaction, using a validated instrument,
associated with each type of vascular access, the incidence
of unnecessary dialysis access creations/placements, and
the impact of potential outcomes (eg, complications,
procedures, hospitalizations) on patient satisfaction and
overall patient burden.
The ESKD Life-Plan may consider alternate environments
for dialysis that may be more suitable for some
patients; as such, further research may help determine and
validate strategies for the ideal vascular access for these
environments, such as home HD.
Timing, Preparation, and Planning for Creation/
Insertion of Vascular Access/ Vessel Preservation
 Validate ESKD prediction equations in large CKD populations
for their use to facilitate vascular access creation
and use (eg, kidney failure risk equation). Test whether
use of prediction equations to assist with timing of
vascular access creation results in improved readiness
and/or additional unnecessary vascular access creation/
insertions.
 Develop and validate strategy/criteria for timing of
referral of PD patients for HD vascular access
creation.
 Develop and validate strategy/criteria for referral of
transplant patients for HD vascular access creation.
 Develop algorithms for individualized vascular access
site selection based on available locations, urgency
of need, and feasibility to provide lifelong access.
 Develop and validate accurate patient-specific estimates
of the predicted duration of HD and predicted probability
of AVF maturation.
 Assess feasibility of alternative options for blood access.
 Assess the impact of a transradial approach for endovascular
interventions (eg, cardiovascular or other) on
future vascular access creation and outcomes.
 Determine whether small-bore internal jugular vein
catheters result in a lower incidence of central venous
stenosis than larger internal jugular vein catheters.
 Determine whether the use of small-bore internal jugular
catheters instead of PICCs may reduce central
venous stenosis.
 Determine and validate the criteria and timing of
creating an AV access in a “failing” PD patient.
 Determine and validate the criteria and timing of creating
an AV access in a “failing” kidney transplant patient.
 Investigate in which patients the decline of eGFR appears
to slow or halt after AVF creation, and why this
may occur.
Patient and Vessel Examinations Preoperative
Considerations
 Determine the optimal training methods for preoperative
clinical examination to assess patients and their
vessels to determine the most suitable type and location
of their vascular access.
 Studies are needed to examine the influence of radialapproach
angiograms on future vascular access
outcomes.
 Develop and validate approaches to reduce potential
damage to central and peripheral vessels by providers
throughout the health care system.
 Research and develop tools for patient education and
vessel preservation to optimize vascular access choice,
creation, and use.
Vascular Access Types: Incident and Prevalent
Patients
 Develop and test risk prediction models to assist patientspecific
decision making regarding choice of vascular
access. Because it is unlikely that randomized trials will
be performed to compare different initial or subsequent
vascular access types, we must rely on high-quality
observational data to inform these algorithms. Specifically,
data on expected probability of maturation, likely
length of time until cannulation, incidence of various
complications, and likely length of AV access survival
will be needed, ideally for numerous strata of patient
characteristics (eg, age, sex, race, life expectancy,
number and severity of comorbid conditions). For
specific areas where existing data are lacking, provide
conflicting results, or are susceptible to substantial bias,
new analyses and studies will be required.
Research Recommendations
S138 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
 Develop, validate, and implement the standardized
definitions for maturation, patency, and specific complications
to provide consistency across studies and
allow development of decision-making tools.
Vascular Access Locations
 Determine whether large arteries (>2 mm) with higher
baseline flows are associated with greater risk of flowassociated
problems.
 Identify criteria for upper arm as first AV access choice.
 Evaluate the impact of real time ultrasound evaluation of
vessels by the operating surgeon on identifying the
optimal type and location for AV access creation and its
impact on maturation and use.
AV Access Creation
 The preponderance of stenosis in specific anatomic locations
suggests that local hemodynamics play a significant
role in its development. The availability of
better imaging techniques and CFD models provide an
opportunity to model hemodynamics and shear stress
patterns. New CFD models, specific for AV access,
should be developed and validated for assisting AV access
decision making.
 Studies of hemodynamics (eg, flow, shear stress) as a
causative or predictive factor of AV access outcomes,
including outflow vein and juxta-anastomotic stenosis,
are needed.
 Evaluate a variety of anastomotic configurations and
techniques, including the end-to-side and side-to-side
configurations, the piggyback straight-line onlay technique
(pSLOT), and the radial artery deviation and
reimplantation (RADAR) technique.
 Investigate technologies to assist with AVF maturation,
including The Fistula Assist Device in AVF Maturation,
and the role of BAM in the setting of RCTs.
 Evaluate ultrasound-based objective criteria to assess
suitability for AV access.
 One-stage versus 2-stage basilic vein transpositions need
to be studied further in the setting of RCTs.
 Evaluate novel techniques for surgical and percutaneous
creation of autogenous AV access.
 Determine whether endoAVF creation can result in a
clinically durable and cost-effective AV access compared
with traditional surgical AV access creation and
maintenance.
Novel Materials and AV Access
 Validate the potential benefits of current biologic grafts.
 Develop and test novel nonautogenous graft materials
and creation techniques.
 Develop and test novel techniques for surgical and
percutaneous creation of autogenous AV access.
 Clinical trials are needed to identify the optimal CVC
with the best long-term durability and survival and
lowest incidence of complications, including central
venous stenosis, vessel injury or thrombosis, CRBSI, and
CVC dysfunction.
 Develop and test novel CVC materials to minimize
complications.
 Catheter insertion: Additional clinical studies are needed
to identify the ideal means to insert a NT-CVC or
tunneled CVC for HD. Imaging appears to favorably
affect successful placement and may reduce complication
rates.
 Newer technologies include vein-localizing tools based
on near-infrared spectroscopy. Studies are needed to
determine whether this technology has application in
adults for CVC placement and whether it warrants
comparison to real-time ultrasound as an imaging
technique to enhance CVC placement.
 Post–AV access creation/CVC insertion considerations:
Test the impact of resources provided by the Fistula First
Catheter Last Work Group Coalition on AVF maturation
and usability.
 Study the indications for secondary interventions (surgical
and endovascular) to help AV access maturation.
Vascular Access Use
 Test the safety, efficacy, and impact on health care resources
and patient outcomes of ultrasound-guided
cannulation in busy, operating dialysis units.
 Identify best practices for mechanics of cannulation,
including needle type and size, angle of insertion, and
graduated flow rates.
 Test effectiveness of simulation models and other
techniques for improving cannulation success, reducing
complications and improving patient satisfaction.
 Define expert cannulator and determine how such expert
cannulators can maintain their expertise and be best
used to improve overall cannulation success within a
unit and for individual patients.
 Identify obstacles to achieving complication-free cannulation
and strategies to mitigate such obstacles.
 RCTs to assess standard needles versus plastic cannulas in
preserving AV access patency and reducing complications.
 RCTs to assess impact of needle size and pump speed on
long-term AV access patency.
 Assess impact of manual compression versus mechanical
clamp use after needle withdrawal on access patency/
stenosis (AV access flow dysfunction).
 Evaluate outcomes associated with alternative cannulation
devices.
 Evaluate the safety, efficacy, and patient satisfaction with
using plastic cannulae.
Research Recommendations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S139
AV Access Flow Dysfunction
AV access flow dysfunction refers to clinically significant abnormalities
in AV access (AVF or AVG) flow or patency
due to underlying stenosis or thrombosis-related
pathology.
 Determine which indicators from a clinical monitoring
examination are most strongly predictive of clinically
significant stenosis.
 Assess the impact of annual mandatory physical examination
skill assessment for all stakeholders on recognizing
early AV access flow dysfunction (similar to BLS
for cardiac arrest).
 Adequately powered RCTs are needed to determine
which surveillance protocols and thresholds for intervention
improve overall AV access patency. Studies
should identify indications and relative benefits/harms
of earlier (pre-emptive) interventions.
 Clinical studies are needed to determine the most
appropriate indications for endovascular versus surgical
intervention.
 Define and validate specific outcome metrics for interventions
for dysfunctional and thrombosed AV access.
 Determine outcomes with surgically corrected occluded
accesses that are followed by a completion angiogram/
imaging ± further corrective procedure. How does this
strategy compare with historical surgical correction
without completion imaging or with endovascular
management?
 Clinical studies are needed to test the potential impact of
multidisciplinary care on AV access patency.
 The effect of far-infrared therapy on AVF and AVG
dysfunction needs to be tested in RCTs in a variety of
dialysis populations.
 RCTs of omega-3 fatty acids are needed to test their
impact on AV access outcomes and define the optimal
formulation and dose.
 Study the patient and AV access outcomes and impact of
(1) ultrasound-guided angioplasty and (2) intravascular
ultrasound guided angioplasty, to limit contrast exposure
in CKD/ESKD patients with residual kidney function
and urine output.
 Stent-grafts versus bare-metal stents for treatment of
central vein stenosis requires more RCT evaluation, with
larger numbers and rigorous conduct and analysis.
 More RCT evaluation of stent-grafts for vascular access
management (primary or secondary) with clinically (rather
than angiogram) based outcomes are urgently required.
 Study is needed in AVFs for multiple modalities of
treatment (eg, stent grafts, drug-eluting balloons, etc).
 Comparative methods of AV access thrombolysis (eg,
surgical versus endovascular) with a variety of shortand
longer-term AVF and AVG outcomes.
 Increasing evidence in the following areas:
B The use of specialized balloons (drug-coated or
cutting) versus standard high-pressure balloons in
the primary treatment of AVF and AVG stenosis.
B The optimal duration of balloon inflation time
during angioplasty to improve intervention primary
patency in the treatment of AVF or AVG stenosis.
B The secondary use of drug-coated balloons after
successful angioplasty with high-pressure balloons
for treatment of stenosis in AVF and AVG.
 Impact of timing of recurrence of stenosis on choice of
treatment modality
 Use of stent grafts in locations other than graft-vein
anastomosis or cephalic arch in brachiocephalic fistulas.
 Optimal treatment of in-stent stenosis that occurs in
stent-grafts.
 The optimal timing of angioplasty/thrombolysis or
thrombectomy in thrombosed AVF and AVG.
 Studies to determine the best measurement that defines
a successful procedure outcome. For example, should it
be a percent relative improvement in lumen size or an
absolute lumen diameter or other measurement? When
should it be measured after the treatment (eg, PTA)
(during the procedure or after?)
AV Access Infection
 Study the impact of aseptic versus sterile cannulation in
AVG infection.
 Evaluate the role of intra-access pressure and cannulation
infiltration in development of AVF cannulation site
infections.
AV Access Aneurysms
 Assess AV access flow rates on incidence and prevalence
of aneurysms.
 Evaluate the role of intra-access pressure in causation of
AVF outflow vein aneurysms.
 Assess the impact of size documentation in medical
record on overall awareness and active intervention by
stakeholders.
 Study the natural history to better determine, manage
and prevent incidence of AV aneurysm rupture, and
fatal hemorrhage.
 Evaluate techniques for AVF salvage and CVC avoidance
while managing aneurysms and bleeding complications.
AV Access Steal
 Further define and establish the predictors for AV access
steal.
 Further define and establish strategies to reduce the
incidence of AV access steal.
 Further define the natural history of mild to moderate
symptoms related to AV access steal.
 Further define and validate the diagnostic criteria for AV
access steal.
 Further define the optimal remedial treatment for AV
access steal.
Research Recommendations
S140 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
 Further define ischemic monomelic neuropathy as a
distinct entity from AV access steal.
 Develop and research the utility and validity of definitions
for steal based on AVF function (high-flow steal vs
low-flow steal).
Treatment of Other AV Access Complications
 Evaluate and develop CVC avoidance techniques to
manage AV access complications
Treatment and Prevention of CVC Complications
 Evaluate the cost/benefit of routine physical examination
and history on CVC use and/or complications.
 RCT comparing normal saline, 1:1,000 heparin, and 4%
citrate as routine CVC lock solution.
 Study the incidence of both central vessel and right atrial
thrombus with noninfected dysfunctional CVC and
develop management guidelines, potentially based on
the size and location of the thrombus.
Catheter Dysfunction
 Develop and validate a standard definition of CVC
dysfunction applicable to unique patient circumstances
to allow comparisons across institutions, studies, and
treatment regimens. Estimate the sensitivity, specificity,
and predictive value of specific markers of dysfunction.
 Assess the impact of earlier intervention—and types of
interventions—for CVC dysfunction.
 Tracking the frequency of dysfunctional and embedded
CVC and the various methods of managing a CVC that is
dysfunctional but embedded.
Prevention of CVC Dysfunction
 Confirm benefit of 1 mg versus 2 mg TPA in maintenance
of CVC patency, both short and long term.
Catheter-Related Infection
 Further develop and validate criteria for CRBSI in hemodialysis
patients.
 Validate diagnostic criteria for exit site and tunnel
infections.
Prevention of CVC Infection
 Rigorously designed and implemented studies are
required to determine an effective surveillance and preemptive
management strategy for CRBSI in subgroups
of patients at high risk.
 Determine predictors of CRBSI in patients receiving
standard infection control practices.
 Evaluate the impact on incidence of CRBSI of strategies
that involve extraluminal exit site and intraluminal
antimicrobial prophylactic care. Studies should be performed
at both the patient and facility level and evaluate
the potential emergence of antibiotic resistant
organisms.
 RCT to assess impact of taking a shower on CRBSI with
healed CVC exit site.
Other Vascular Access-Related Complications
 The natural history and predictors of CVS need to be
understood in greater detail.
 Effective interventions for symptomatic CVS need to be
developed and validated.
 Randomized controlled trials for treatment of catheters
with a fibrin sheath are needed to compare effectiveness
of thrombolytics, catheter exchange, and catheter exchange
with fibrin sheath disruption on outcomes of
patency and infection.
 The association of fibrin sheath incidence with CBRSI
needs to be evaluated.
 The effectiveness of fibrin sheath disruption plus antibiotics
compared with antibiotics alone needs to be
evaluated in terms of CVC dysfunction and incidence of
infection.
 Characterizing catheter-related central vein thrombosis
versus atrial thrombosis and its management principles.
Multidisciplinary Approaches to Vascular Access
 Role of associate degree–level training for dialysis
technician rather than hands-on training only. Standardizing
training curriculum.
 Impact on development and implementation of a standardized
dialysis access training curriculum for all
stakeholders (nephrologist, nurses, surgeons, radiologist)
involved in AV access care.
Endovascular Procedures
 Cost comparison between interventions, PTA, and use
of stent-grafts and/or drug-eluting balloons for maintaining
overall access patency.
 Comparison between drug-eluting balloons and stentgrafts
for overall access patency.
 Comparison between different drug-eluting balloons
and different stent-grafts.
 Drug dose comparison study on impact of drug coated
balloons on venous stenosis in dialysis accesses.
 Determine if and what the role of angioscopy is for
guided interventions.
Surgical Procedures
 Skills and training needs for CVC placement and AV
access creation.
 Defining high-flow AV access, its hemodynamic impact
and treatment options. Should there be an RCT for
treatment options, and if so, what interventions should
be evaluated?
Research Recommendations
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S141
BIOGRAPHICAL AND DISCLOSURE INFORMATION
Guideline Development Work Group
Kenneth Abreo, MD
Dr Abreo is Professor of Medicine, Chief of the Division of
Nephrology, and Vice Chairman of the Department of
Medicine at Louisiana State University Health Shreveport
School of Medicine. After completing his Nephrology
Fellowship training at the University of California–Davis in
Sacramento and the University of Wisconsin in Madison,
he joined the Medicine faculty at the University of Kentucky
in Lexington from 1982 to 1985 and Louisiana State
University Health Sciences Center in Shreveport in 1985.
His early research interests were focused on clinical and
bench research on aluminum toxicity causing bone disease
and anemia in renal failure patients. In the past decade, he
has focused on training Nephrology Fellows in interventional
nephrology. His current research interests are
centered on improving vascular and peritoneal access in
dialysis patients. He has played an active role in the
American Society of Diagnostic and Interventional
Nephrology, most recently as President. He serves on the
Editorial Board of the Journal of Vascular Access. He has been
involved in national and international scientific and
educational programs with American Society of Diagnostic
and Interventional Nephrology, ASN, NKF, ISN, ANZIN,
ERA-EDTA, AVATAR, and VAS. Dr Abreo declares that he
has no relevant financial relationships.
Michael Allon, MD
Dr. Allon is Professor of Medicine at University of Alabama
at Birmingham, where he serves as the Associate Director
for Clinical Affairs and the Medical Director of Dialysis
Operations in the Division of Nephrology. He has a
longstanding clinical research interest in dialysis and, in
particular, in vascular access for hemodialysis. He was the
principal investigator for several clinical dialysis trials
sponsored by the National Institutes of Health, including
HEMO, DAC, and HFM. He has published more than 100
peer-reviewed articles on various aspects of vascular access.
Finally, he has been an invited speaker at numerous
nephrology meetings on various topics related to vascular
access. Dr Allon declares that he has no relevant financial
relationships.
Arif Asif, MD, MHCM
Dr Asif is the Chairman of the Department of Medicine at
Jersey Shore Medical Center and Professor of Medicine at
Seton Hall-Hackensack Meridian School of Health,
Neptune, New Jersey. He completed his residency in Internal
Medicine at Mercy Hospital and Medical Center,
University of Illinois at Chicago, and Fellowship in
Nephrology and Hypertension at the University of Miami,
Miami, Florida. He also received a Master of Health Care
Management and Business Administration degree from
Harvard University, Boston, Massachusetts. He is a
nationally and internationally recognized expert in hemodialysis
vascular access and has organized and chaired
multiple scientific meetings on hemodialysis access. Dr Asif
has been involved in vascular access research since 2000.
He has had numerous funded research projects, received
many teaching awards, and developed multiple training
programs in the area of dialysis vascular access. He has
edited 4 books and authored more than 200 articles and
book chapters. Among his many professional editorial responsibilities,
he is the Section Editor of the Journal of
Vascular Access and the Associate Editor of the American Journal
of Kidney Diseases. He is the Past President of the American
Society of Diagnostic and Interventional Nephrology Society
and currently serves as the Chair of its Clinical
Practice Committee. Dr Asif has consulted for, and received
honoraria from, Alexion Pharmaceuticals, Inc, in 2016;
consulted for Phraxis, Inc, from 2016 through 2018, and
received honoraria from Fresenius USA Marketing, Inc,
in 2016.
Brad C. Astor, PhD, MPH
Dr Astor is Associate Professor in the Departments of
Medicine and Population Health Sciences at the University
of Wisconsin School of Medicine and Public Health. He
serves as the Director of Research for the Division of
Nephrology. He was a medical device reviewer at the US
Food and Drug Administration prior to training as an
epidemiologist at The Johns Hopkins Bloomberg School of
Public Health. He was a faculty member in the Departments
of Epidemiology and Medicine at Johns Hopkins
until 2011, when he joined the University of Wisconsin.
His research covers several different aspects of kidney
disease and its interaction with cardiovascular disease.
Other specific areas of interest include predictors of outcomes
in kidney transplant recipients and hemodialysis
vascular access complications. This research has been
pursued in the general population (Atherosclerosis Risk in
Communities [ARIC] Study, Multi-Ethnic Study of
Atherosclerosis [MESA]) as well as in clinical trials (African
American Study of Kidney Disease and Hypertension
[AASK]) and observational studies of dialysis patients
(Choices for Healthy Outcomes in Caring for ESKD
[CHOICE]) and kidney transplant recipients (Wisconsin
Allograft Recipient Database [WisARD]). Dr Astor consulted
for VascAlert in 2018 and 2019.
Marc Glickman, MD
Dr Glickman is a retired vascular surgeon who has written
more than 100 articles on vascular access surgery. He has
written several chapters in books on vascular access surgery
as well. He was previous President of the Vascular Access
Society of the Americas, part of the clinical faculty of the
Eastern Virginia Medical School. He has been principal
investigator for many vascular access graft studies that are
Biographical and Disclosure Information
S142 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
currently in use today. He has lectured extensively nationally
and internationally on vascular access surgery. Dr
Glickman received honoraria from Bard Peripheral
Vascular from 2016 through 2018 and consulted for WL
Gore & Associates, Inc (2016); Merit Medical Systems Inc
(2016-2018); LeMaitre Vascular Inc (2016, 2018); Zimmer
Biomet Holdings, Inc (2017); and Bard Peripheral
Vascular (2018). Dr Glickman has also been employed by
Hancock Jaffe (2016 to the present).
Janet Graham, MHScN, CNeph(C)
Ms Graham’s career has focused on the care of patients
with chronic kidney disease over almost 3 decades.
Currently, she is the Clinical Director of Nephrology at The
Ottawa Hospital (TOH) and Regional Director of
Nephrology Champlain LHIN Ontario Renal Network
(ORN), and she recently completed a secondment as
Clinical Education and Quality Improvement at the ORN,
leading the development and implementation of both
clinical education and quality improvement initiatives at
the provincial level. Ms Graham’s career has spanned the
entire care continuum in renal care, and she has held a
number of leadership positions at TOH. She holds a Masters
of Health Science degree in Nursing and has conducted
clinical research in the area of dialysis access, with several
publications in this area. Ms Graham declares that she has
no relevant financial interests.
Thomas S. Huber, MD, PhD
Dr Huber is Professor and Chief of the Division of Vascular
Surgery at the University of Florida College of Medicine.
He has a longstanding interest in hemodialysis access and
was one of the Principal Investigators for the National
Institutes of Health/National Institute of Diabetes and
Digestive and Kidney Diseases Hemodialysis Fistula
Maturation Study. He has served on the editorial boards of
the Journal of Vascular Surgery and the Yearbook of Surgery while
co-editing Mastery of Vascular and Endovascular Surgery. He
currently serves on the Vascular Surgery Board of the
American Board of Surgery. Dr Huber declares that he has
no relevant financial relationships.
Timmy Lee, MD
Dr Lee is Professor of Medicine in the Department of
Medicine and Division of Nephrology, with a secondary
appointment in the Department of Biomedical Engineering
at the University of Alabama at Birmingham. He received
his medical degree from the Louisiana State University
Health Sciences Center in Shreveport and completed his
Internal Medicine residency and Nephrology fellowship at
the University of Alabama at Birmingham, Nephrology
research fellowship at the University of Alabama at Birmingham,
and Masters of Science in Public Health degree
at the University of Alabama at Birmingham. Dr Lee
currently serves as the Associate Director of Interventional
Nephrology, Associate Nephrology Fellowship Director,
Associate Director of the Nephrology Research Training
Center, Associate Section Chief, and Director of the Hemodialysis
Program at the Birmingham Veterans Affairs
Medical Center. He has been involved in hemodialysis
vascular access research since 2002 and has more than 50
publications in vascular access research. He has active
research programs in clinical trials and large epidemiologic
studies in dialysis vascular access and a laboratory-based
translational research program in dialysis vascular access
studying human vascular access blood vessel tissue biorepositories
and mechanisms of arteriovenous fistula
dysfunction using animal models (mouse, rat, and pig).
The goal of his research program is to develop novel
therapeutics to prevent and treat complications of hemodialysis
vascular access dysfunction and improve the delivery
and processes of care for patients requiring a
hemodialysis vascular access. Dr Lee’s research program is
currently funded by the National Institutes of Health and
Veterans Affairs Medical Center. He serves a counselor in
the American Society of Diagnostic and Interventional
Nephrology. Dr. Lee served as a consultant for Merck Sharp
& Dohme Corporation (2017, 2019) and Boston Scientific
(2019).
Charmaine E. Lok, MD, MSc, FRCP(C) (Chair)
Dr Lok is a Professor of Medicine, Faculty of Medicine, at
the University of Toronto and Senior Scientist at the Toronto
General Hospital Research Institute. She is also associated
with the Department of Health Research Methods,
Evidence, and Impact, Faculty of Health Sciences,
McMaster University. Dr Lok is the Medical Director of
both the chronic kidney diseases and hemodialysis programs
at the University Health Network–Toronto General
Hospital, Toronto, Ontario, Canada. Her research focus is
on chronic kidney disease (CKD) and end-stage kidney
disease (ESKD) outcomes. She has a special interest in
improving dialysis access outcomes and reducing adverse
cardiovascular events in CKD/ESKD. She is active in raising
awareness of CKD and ESKD and its importance in population
health. Dr Lok is involved in a variety of local and
international scientific and educational programs
including, Canadian Institutes of Health Research (CIHR),
Kidney Foundation of Canada (KFOC), Dialysis Outcomes
and Practice Patterns Study, National Kidney Foundation
(NKF), American Society of Nephrology (ASN), Vascular
Access Society of the Americas (VASA), American Society
of Diagnostic and Interventional Nephrology, and Kidney
CARE Network International. Dr Lok declares that she has
no relevant financial interests.
Louise M. Moist, MD, MSc
Dr Moist is a nephrologist at Victoria Hospital, Ontario,
Canada and Professor of Medicine, Epidemiology and
Biostatistics; Associate Chair of the Division of
Biographical and Disclosure Information
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S143
Nephrology; and Scientist in the Program of Experimental
Medicine at Western University. Her clinical and research
interests are focused on chronic kidney disease, with a
specific expertise in vascular access for hemodialysis patient.
Dr Moist has a number of leadership roles, including
The Ontario Renal Network Physician Lead for Dialysis
Access, integrating change to improve vascular access
practice and reduce catheter use. She has chaired and been
involved in several guideline groups, including CSN anemia
guidelines, timing of dialysis start, and vascular access.
Dr Moist is active in education, clinical care, and research,
with more than 150 peer-reviewed academic papers and
numerous research grants. She has received the University
of Western Ontario award for Excellence for Teaching and
for Excellence in Research. Dr. Moist has served on a
speaker’s bureau and as a consultant for Otsuka America
Pharmaceutical (2018) and Janssen Pharmaceuticals
(2018). She has also served as a consultant for Boehringer
Ingelheim in 2018 and on an advisory board for Novartis
(2019), AstraZeneca (2019), and Novo Nordisk (2019).
Dheeraj K. Rajan, MD, FRCP(C)
Dr Rajan completed his Diagnostic Radiology residency at
Wayne State University in 1999 and Fellowship in Vascular
and Interventional Radiology at the University of Pennsylvania
in 2000. Over his career, he has published 100
articles, primarily focused on arterial and dialysis interventions,
multiple book chapters, and a textbook titled
Essentials of Percutaneous Dialysis Interventions. He is a Professor of
Medicine and the Division Chief of VIR at the University of
Toronto. Dr Rajan also sits on various committees for the
Society of Interventional Radiology, Cardiac Care Network
of Ontario, and the Ontario Renal Network. He formerly
was an Associate Editor for the Journal of Vascular and Interventional
Radiology and reviews for multiple medical journals.
Dr Rajan’s current focus is on the percutaneous creation of
dialysis fistulas, and he was one of the pioneers for the
procedure itself. He also serves as an advisor to multiple
start-up and established companies with devices focused
on hemodialysis interventions. Dr. Rajan served as a
consultant for Becton Dickinson (2018), TVA Medical
(2016), and Bard Medical (2016). He also served on a
speaker’s bureau for Gore Medical (2018) and had stocks/
bonds with TVA Medical (2016).
Cynthia Roberts, RN, CNN
Ms Roberts is a Nephrology and Vascular Access Nurse and
has for patients with chronic kidney and end-stage renal
disease for 28 years. She works with Renal Research
Institute, partnering with the University of North Carolina
(UNC) at Chapel Hill Nephrology and Hypertension division
and UNC Kidney Center. She specializes in developing
patient care models that emphasize collaboration of
care with dedicated vascular access surgery and interventional
clinic systems and nephrology integrated care
management. She has multiple publications in ANNA
Nursing Journal and Nephrology News and Issues, where she served
as editor of the vascular access quarterly column. Ms
Roberts declares that she has no relevant financial interests.
Surendra Shenoy, MD, PhD
Dr Shenoy is a Professor of Surgery and the Director of the
Living Donor Transplantation Program at the Washington
University School of Medicine in Saint Louis, Missouri. His
clinical and research interests include liver, kidney, and
living donor transplantation; liver; and dialysis access surgery.
He serves on the Board of Directors and is the immediate
past president of the Vascular Access Society of
Americas (VASA). He is on the Editorial Board of the Journal of
Vascular Access and serves as the VASA Editor for the Americas.
Dr Shenoy was the Cochair for the working group that was
tasked with describing appropriate endpoints for dialysis
vascular access trials established by the Kidney Health
Initiative of the American Society of Nephrology. He has
been actively involved in several clinical research projects
related to abdominal organ transplantation and vascular
access for hemodialysis. He has published several innovative
surgical techniques in the field of transplantation and
vascular access. Dr Shenoy consulted for CR Bard, Inc, in
2016 and Bard Peripheral Vascular, Inc, in 2018 and
received an honorarium from Getinge USA in 2019.
Tushar Vachharajani, MD
Dr Vachharajani is an Adjunct Professor in the Department
of Medicine at the University of North Carolina, Chapel
Hill and Chief of Nephrology and Medical Director of the
Hemodialysis Program at the Salisbury Veterans Affairs
Health Care System, North Carolina. Dr Vachharajani is an
interventional nephrologist with international eminence
who holds several leadership positions with International
Society of Nephrology. He has published more than 70
peer-reviewed scientific papers and several book chapters,
and he is an Associate Editor for the Journal of Vascular Access
(American Society of Diagnostic and Interventional
Nephrology [ASDIN]). He served as a Co-Lead on the
Access Monitoring Work Group of Fistula First Breakthrough
Initiative and as a Chair for the Medical Review
Board of ESKD Network 6. He is passionate about training
and improving global awareness of dialysis access care
through various national and international professional
organizations, including ISN, ASN, NKF, ASDIN,
AVATAR, ISHD, and Kidney Education Foundation. Besides
serving as a Cochair for the Interventional
Nephrology Workshop at the World Congress of
Nephrology in 2017 and 2019, he has helped organize
vascular access symposiums, given scientific presentations,
and conducted hands-on workshop in 15 different
countries. Dr Vachharajani received the Gerald Beathard
Award for Excellence in Teaching and Scholarly Activity
from ASDIN. Dr Vachharajani served as a consultant for F.
Hoffmann-La Roche AG in 2016.
Biographical and Disclosure Information
S144 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Rudolph P. Valentini, MD
Dr Valentini is a Clinical Professor of Pediatrics at Wayne
State University School of Medicine and the Chief Medical
Officer for the Children’s Hospital of Michigan (CHM). He
served as the Director of Dialysis Services at CHM for 10
years before taking on his role as Chief Medical Officer. He
has authored or coauthored a number of articles and book
chapters on vascular access in the pediatric hemodialysis
patient. This clinical passion has led to a near elimination
of central venous catheters for delivery of chronic hemodialysis
at his center. He has been an invited speaker at
regional and national meetings to speak on the topic of the
ideal vascular access choice for the pediatric hemodialysis
patient. He was the American Society of Pediatric
Nephrology representative and participant on the Center
for Medicaid and Medicare Services Technical Expert Panel
on Dialysis Vascular Access in 2015. He has also served as
the pediatric representative on the Medical Review Committee
for the Midwest Kidney Network (formerly
Network 11) and was a longstanding member for the
Midwest Pediatric Nephrology Consortium review committee.
Dr Valentini has received royalties from UpToDate
(2016 to the present) and World Scientific (2018).
Alexander S. Yevzlin, MD
Dr Yevzlin graduated magna cum laude from Dartmouth
College. He did his residency in Internal
Medicine at the University of Michigan and fellowship
in Nephrology at Northwestern. Dr Yevzlin is
currently Professor of Medicine and Director of
Interventional Nephrology at the University of Michigan.
He has presented and published more than 150
abstracts, invited lectures, and articles. He is an
internationally recognized leader in the field of
Interventional Nephrology, having edited the first 3
textbooks on the subject, and is a past President of the
American Society of Diagnostic and Interventional
Nephrology. In addition to his academic contributions,
Dr Yevzlin has been involved the invention,
design, and reduction to practice of multiple medical
devices in his role as Chief Medical Officer, Chief
Science Officer, and founder of multiple start-up
biotech companies. Dr Yevzlin served as a consultant
for AV Medical Technologies (2018), Covidien LP
(2016-2018), Lutonix, Inc (2018), and Phraxis, Inc
(2016-2018). He also receives interest from stocks in
Phraxis, Inc (2016 to the present).
Evidence Review Team
Michelle Brasure, PhD, MSPH, MLIS, is Program Manager
and Medical Librarian for the Minnesota EvidenceBased
Practice Center. She has extensive experience leading
multidisciplinary systematic review teams on a variety
of topics. Dr. Brasure reported no relevant financial
relationships.
Nancy Greer, PhD, is a senior research associate in the
Minneapolis Center for Chronic Disease Outcomes
Research and Program Manager for the Minneapolis VA
Evidence-Synthesis Program. She has extensive experience
in leading multidisciplinary teams in conducting evidence
synthesis reports across a wide range of topics. Dr. Greer
reported no relevant financial relationships.
Areef Ishani, MD, MS, is the Chief of the Primary Care
Service Line at the Minneapolis VA Health Care System and
a Professor of Medicine at the University of Minnesota. His
primary research interests are in chronic kidney disease,
acute kidney injury, and end-stage kidney disease. Dr
Ishani reported no relevant financial relationships.
Roderick MacDonald, MS, is a senior research assistant
in the Minneapolis VA Center for Chronic Disease Outcomes
Research. He has nearly 20 years of experience in
conducting systematic reviews across a wide range of
topics. Mr MacDonald reported no relevant financial
relationships.
Victoria Nelson, MSc, is a research fellow in the
Minnesota Evidence-Based Practice Center. Her primary
research interests are research methodology,
evidence synthesis, health psychology, and behavior
change. Ms Nelson reported no relevant financial
relationships.
Carin Olson, MD, MS, is a systematic reviewer, medical
editor and writer, and physician, working with the Minnesota
Evidence-Based Practice Center at the University of
Minnesota. Her interests include research methodology
(especially relating to meta-analysis and publication bias),
research ethics, injury prevention, and cardiopulmonary
resuscitation. Dr Olson reported no relevant financial
relationships.
Yelena Slinin, MD, MS, is a nephrologist at Kaiser
Permanente in California. Her primary research interests
are optimal medical care delivery and outcomes of patients
with kidney disease, evidence-based medicine, and critical
literature appraisal. Dr Slinin reported no relevant financial
relationships.
Timothy J. Wilt, MD, MPH, is a Professor of Medicine
at the University of Minnesota and Core Investigator in the
Center for Chronic Disease Outcomes Research at the
Veterans Affairs Medical Center in Minneapolis, Minnesota.
He has a research agenda that involves conducting clinical
trials, systematic reviews, and meta-analysis to evaluate the
effects of health care interventions on outcomes in adults
with chronic diseases. Dr Wilt reported no relevant
financial relationships.
Evidence Review Team
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S145
SUPPLEMENTARY MATERIAL
Supplement 1: Literature Search Strategy (PDF)
Supplement 2: ESKD Life-Plan: Patient-Physician Shared Documentation
(PDF)
Supplement 3: Evidence Review Team Tables (PDF)
Supplement 4: Supplement to AV Access Infections (PDF)
Supplementary Material
S146 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
References
1. Lee T, Mokrzycki M, Moist L, Maya I, Vazquez M, Lok CE.
Standardized definitions for hemodialysis vascular access. Semin
Dial. 2011;24(5):515-524.
2. Bakken AM, Protack CD, Saad WE, Lee DE, Waldman DL,
Davies MG. Long-term outcomes of primary angioplasty and primary
stenting of central venous stenosis in hemodialysis patients. J Vasc
Surg. 2007;45(4):776-783.
3. Lee T, Barker J, Allon M. Needle infiltration of arteriovenous
fistulae in hemodialysis: risk factors and consequences. Am J Kidney
Dis. 2006;47(6):1020-1026.
4. Beathard GA, Arnold P, Jackson J, Litchfield T. Physician Operators
Forum of RMSL. Aggressive treatment of early fistula failure.
Kidney Int. 2003;64(4):1487-1494.
5. Beathard GA, Lok CE, Glickman MH, et al. Definitions and end
points for interventional studies for arteriovenous dialysis access.
Clin J Am Soc Nephrol. 2018;13(3):501-512.
6. Inker LA, Astor BC, Fox CH, et al. KDOQI US commentary
on the 2012 KDIGO clinical practice guideline for the evaluation
and management of CKD. Am J Kidney Dis. 2014;63(5):713-
735.
7. KDIGO 2012 Clinical practice fuideline for the evaluation and
management of chronic kidney disease: summary of recommendation
statements. Kidney Int Suppl. 2013;3(1):5-14.
8. United States Renal Data System. 2018 USRDS Annual Data
Report: Epidemiology of Kidney Disease in the United States.
Bethesda, MD: National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases; 2018.
9. Alonso-Coello P, Oxman AD, Moberg J, et al. GRADE Evidence
to Decision (EtD) frameworks: a systematic and transparent
approach to making well informed healthcare choices. 2: Clinical
practice guidelines. BMJ. 2016;353:i2089.
10. Alonso-Coello P, Schunemann HJ, Moberg J, et al. GRADE
Evidence to Decision (EtD) frameworks: a systematic and transparent
approach to making well informed healthcare choices. 1:
Introduction. BMJ. 2016;353:i2016.
11. Viswanathan M, Ansari MT, Berkman ND, et al. AHRQ
methods for effective health care assessing the risk of bias of individual
studies in systematic reviews of health care interventions. In:
Methods Guide for Effectiveness and Comparative Effectiveness
Reviews. Rockville, MD: Agency for Healthcare Research and
Quality (US); 2008.
12. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1.
Introduction-GRADE evidence profiles and summary of findings tables.
J Clin Epidemiol. 2011;64(4):383-394.
13. KDOQI clinical practice guidelines for vascular access. Am J
Kidney Dis. 2006;48:S176-S247.
14. Uhlig K, Macleod A, Craig J, et al. Grading evidence and
recommendations for clinical practice guidelines in nephrology. A
position statement from Kidney Disease: Improving Global Outcomes
(KDIGO). Kidney Int. 2006;70(12):2058-2065.
15. Lok CE, Davidson I. Optimal choice of dialysis access for
chronic kidney disease patients: developing a life plan for dialysis
access. Semin Nephrol. 2012;32(6):530-537.
16. Woo K, Lok CE. New insights into dialysis vascular access:
what is the optimal vascular access type and timing of access creation
in CKD and dialysis patients? Clin J Am Soc Nephrol.
2016;11(8):1487-1494.
17. Fistula First initiative. 2012. Accessed May 4 2012.
18. Woo K, Goldman DP, Romley JA. Early failure of dialysis access
among the elderly in the era of Fistula First. Clin J Am Soc
Nephrol. 2015;10(10):1791-1798.
19. Brown RS, Patibandla BK, Goldfarb-Rumyantzev AS. The
survival benefit of “Fistula First, Catheter Last” in hemodialysis is
primarily due to patient factors. J Am Soc Nephrol. 2017;28(2):645-
652.
20. Gomes A, Schmidt R, Wish J. Re-envisioning Fistula First in a
patient-centered culture. Clin J Am Soc Nephrol. 2013;8(10):1791-
1797.
21. Disbrow DE, Cull DL, Carsten 3rd CG, Yang SK, Johnson BL,
Keahey GP. Comparison of arteriovenous fistulas and arteriovenous
grafts in patients with favorable vascular anatomy and equivalent
access to health care: is a reappraisal of the Fistula First initiative
indicated? J Am Coll Surg. 2013;216(4):679-685; discussion 685-
676.
22. Schinstock CA, Albright RC, Williams AW, et al. Outcomes of
arteriovenous fistula creation after the Fistula First initiative. Clin J
Am Soc Nephrol. 2011;6(8):1996-2002.
23. DeSilva RN, Patibandla BK, Vin Y, et al. Fistula First is not
always the best strategy for the elderly. J Am Soc Nephrol.
2013;24(8):1297-1304.
24. Woo K, Lok CE. New insights into dialysis vascular access:
what is the optimal vascular access type and timing of access creation
in CKD and dialysis patients? Clin J Am Soc Nephrol.
2016;11(8):1487-1494.
25. Kalloo S, Blake PG, Wish J. A patient-centered approach to
hemodialysis vascular access in the era of Fistula First. Semin Dial.
2016;29(2):148-157.
26. Vachharajani TJ, Moossavi S, Jordan JR, Vachharajani V,
Freedman BI, Burkart JM. Re-evaluating the Fistula First initiative in
octogenarians on hemodialysis. Clin J Am Soc Nephrol. 2011;6(7):
1663-1667.
27. Drew DA, Lok CE. Strategies for planning the optimal dialysis
access for an individual patient. Curr Opin Nephrol Hypertens.
2014;23(3):314-320.
28. Allon M, Lockhart ME, Lilly RZ, et al. Effect of preoperative
sonographic mapping on vascular access outcomes in hemodialysis
patients. Kidney Int. 2001;60(5):2013-2020.
29. Schwab SJ. Vascular access for hemodialysis. Kidney Int.
1999;55:2078-2090.
30. Lok CE, Sontrop JM, Tomlinson G, et al. Cumulative patency
of contemporary fistulas versus grafts (2000-2010). Clin J Am Soc
Nephrol. 2013;8(5):810-818.
31. Dember LM, Beck GJ, Allon M, et al. Effect of clopidogrel on
early failure of arteriovenous fistulas for hemodialysis: a randomized
controlled trial. JAMA. 2008;299(18):2164-2171.
32. Lacson Jr E, Lazarus JM, Himmelfarb J, Ikizler TA, Hakim RM.
Balancing Fistula First with Catheters Last. Am J Kidney Dis.
2007;50(3):379-395.
33. Lok CE. Fistula First initiative: advantages and pitfalls. Clin J
Am Soc Nephrol. 2007;2(5):1043-1053.
34. Ravani P, Palmer SC, Oliver MJ, et al. Associations between
hemodialysis access type and clinical outcomes: a systematic review.
J Am Soc Nephrol. 2013;24(3):465-473.
35. Quinn RR, Oliver MJ, Devoe D, et al. The effect of predialysis
fistula attempt on risk of all-cause and access-related death. J Am
Soc Nephrol. 2017;28(2):613-620.
36. Quinn RR, Ravani P. Fistula-first and catheter-last: fading
certainties and growing doubts. Nephrol Dial Transplant.
2014;29(4):727-730.
37. Alhassan SU, Adamu B, Abdu A, Aji SA. Outcome and
complications of permanent hemodialysis vascular access in Nigerians:
A single centre experience. Annals of African Medicine.
2013;12(2):127.
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S147
38. Arhuidese IJ, Obeid T, Hicks C, et al. Vascular access modifies
the protective effect of obesity on survival in hemodialysis patients.
Surgery. 2015;158(6):1628-1634.
39. Bray BD, Boyd J, Daly C, et al. Vascular access type and risk
of mortality in a national prospective cohort of haemodialysis patients.
QJM. 2012;105(11):1097-1103.
40. Charlton-Ouw KM, Nosrati N, Miller 3rd CC, Coogan SM,
Safi HJ, Azizzadeh A. Outcomes of arteriovenous fistulae compared
with heparin-bonded and conventional grafts for hemodialysis access.
J Vasc Access. 2012;13(2):163-167.
41. Clark WF, Na Y, Rosansky SJ, et al. Association between
estimated glomerular filtration rate at initiation of dialysis and mortality.
CMAJ. 2011;183(1):47-53.
42. DeSilva RN, Sandhu GS, Garg J, Goldfarb-Rumyantzev AS.
Association between initial type of hemodialysis access used in the
elderly and mortality. Hemodialysis International. 2012;16(2):233-
241.
43. Di Iorio BR, Bellizzi V, Cillo N, et al. Vascular access for hemodialysis:
the impact on morbidity and mortality. J Nephrol.
2004;17(1):19-25.
44. Foley RN, Chen SC, Collins AJ. Hemodialysis access at
initiation in the United States, 2005 to 2007: still "catheter first".
Hemodial Int. 2009;13(4):533-542.
45. Gonzalez E, Kashuk JL, Moore EE, Linas S, Sauaia A. Twostage
brachial-basilic transposition fistula provides superior patency
rates for dialysis access in a safety-net population. Surgery.
2010;148(4):687-693. discussion 693-684.
46. Gruss E, Portoles J, Tato A, et al. Clinical and economic repercussions
of the use of tunneled haemodialysis catheters in a
health area. Nefrologia. 2009;29(2):123-129.
47. Jorna T, Methven S, Ravanan R, Weale AR, Mouton R. 30-day
mortality after haemodialysis vascular access surgery: a retrospective
observational study. J Vasc Access. 2016;17(3):215-219.
48. Kasza J, Wolfe R, McDonald SP, Marshall MR,
Polkinghorne KR. Dialysis modality, vascular access and mortality in
end-stage kidney disease: a bi-national registry-based cohort study.
Nephrology. 2016;21(10):878-886.
49. Krzanowski M, Janda K, Chowaniec E, Sulowicz W. Hemodialysis
vascular access infection and mortality in maintenance hemodialysis
patients. Przegl Lek. 2011;68(12):1157-1161.
50. Lacson Jr E, Wang W, Hakim RM, Teng M, Lazarus JM. Associates
of mortality and hospitalization in hemodialysis: potentially
actionable laboratory variables and vascular access. Am J Kidney
Dis. 2009;53(1):79-90.
51. Lacson Jr E, Wang W, Lazarus JM, Hakim RM. Change in
vascular access and mortality in maintenance hemodialysis patients.
Am J Kidney Dis. 2009;54(5):912-921.
52. Lacson Jr E, Wang W, Lazarus JM, Hakim RM. Change in
vascular access and hospitalization risk in long-term hemodialysis
patients. Clin J Am Soc Nephrol. 2010;5(11):1996-2003.
53. Leake AE, Yuo TH, Wu T, et al. Arteriovenous grafts are
associated with earlier catheter removal and fewer catheter days in
the United States Renal Data System population. J Vasc Surg.
2015;62(1):123-127.
54. Lioupis C, Mistry H, Rix T, Chandak P, Tyrrell M, Valenti D.
Comparison among transposed brachiobasilic, brachiobrachial
arteriovenous fistulas and Flixene™ vascular graft. J Vasc Access.
2011;12(1):36-44.
55. Malas MB, Canner JK, Hicks CW, et al. Trends in incident
hemodialysis access and mortality. JAMA Surgery. 2015;150(5):
441-448.
56. Moist LM, Trpeski L, Na Y, Lok CE. Increased hemodialysis
catheter use in Canada and associated mortality risk: data from the
Canadian Organ Replacement Registry 2001-2004. Clin J Am Soc
Nephrol. 2008;3(6):1726-1732.
57. Ng YY, Hung YN, Wu SC, Ko PJ. Characteristics and 3-year
mortality and infection rates among incident hemodialysis patients
with a permanent catheter undergoing a first vascular access conversion.
Clin Exp Nephrol. 2014;18(2):329-338.
58. Ong S, Barker-Finkel J, Allon M. Long-term outcomes of
arteriovenous thigh grafts in hemodialysis patients: a comparison
with tunneled dialysis catheters. Clin J Am Soc Nephrol. 2013;8(5):
804-809.
59. Park HS, Kim WJ, Kim YK, et al. Comparison of outcomes
with arteriovenous fistula and arteriovenous graft for vascular access
in hemodialysis: a prospective cohort study. Am J Neph.
2016;43(2):120-128.
60. Portoles J, Lopez-Gomez JM, Gruss E, Aljama P,
Group MARS. Course of vascular access and relationship with
treatment of anemia. Clin J Am Soc Nephrol. 2007;2(6):1163-1169.
61. Praga M, Merello JI, Palomares I, et al. Type of vascular access
and survival among very elderly hemodialysis patients.
Nephron. 2013;124(1-2):47-53.
62. Wasse H, Speckman RA, McClellan WM. Arteriovenous fistula
use is associated with lower cardiovascular mortality compared
with catheter use among ESRD patients. Semin Dial. 2008;21(5):
483-489.
63. Woo K, Yao J, Selevan D, Hye RJ. Influence of vascular access
type on sex and ethnicity-related mortality in hemodialysisdependent
patients. Permanente J. 2012;16(2):4-9.
64. Wystrychowski G, Kitzler TM, Thijssen S, Usvyat L,
Kotanko P, Levin NW. Impact of switch of vascular access
type on key clinical and laboratory parameters in chronic
haemodialysis patients. Nephrol Dial Transplant. 2009;24(7):
2194-2200.
65. Xue H, Ix JH, Wang W, et al. Hemodialysis access usage
patterns in the incident dialysis year and associated catheter-related
complications. Am J Kidney Dis. 2013;61(1):123-130.
66. Zhang JC, Al-Jaishi AA, Na Y, de Sa E, Moist LM. Association
between vascular access type and patient mortality among elderly
patients on hemodialysis in Canada. Hemodial Int. 2014;18(3):616-
624.
67. Ravani P, Quinn R, Oliver M, et al. Examining the association
between hemodialysis access type and mortality: the role
of access complications. Clin J Am Soc Nephrol. 2017;12(6):
955-964.
68. Grubbs V, Wasse H, Vittinghoff E, Grimes BA, Johansen KL.
Health status as a potential mediator of the association between
hemodialysis vascular access and mortality. Nephrol Dial Transplant.
2014;29(4):892-898.
69. Quinn R, Ravani P. ACCESS HD pilot: A randomised feasibility
trial Comparing Catheters with fistulas in Elderly patientS
Starting haemodialysis. BMJ Open. 2016;6(11):e013081.
70. Schwab SJ, Harrington JT, Singh A, et al. Vascular access for
hemodialysis. Kidney Int. 1999;55(5):2078-2090.
71. Lee T, Barker J, Allon M. Comparison of survival of upper arm
arteriovenous fistulas and grafts after failed forearm fistula. J Am Soc
Nephrol. 2007;18(6):1936-1941.
72. Snyder DC, Clericuzio CP, Stringer A, May W. Comparison of
outcomes of arteriovenous grafts and fistulas at a single Veterans’
Affairs medical center. Am J Surg. 2008;196(5):641-646.
73. Harms JC, Rangarajan S, Young CJ, Barker-Finkel J, Allon M.
Outcomes of arteriovenous fistulas and grafts with or without
intervention before successful use. J Vasc Surg. 2016;64(1):155-
162.
74. Rooijens PP, Burgmans JP, Yo TI, et al. Autogenous radialcephalic
or prosthetic brachial-antecubital forearm loop AVF in patients
with compromised vessels? A randomized, multicenter study
of the patency of primary hemodialysis access. J Vasc Surg.
2005;42(3):481-486; discussions 487.
References
S148 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
75. Keuter XH, De Smet AA, Kessels AG, van der Sande FM,
Welten RJ, Tordoir JH. A randomized multicenter study of the
outcome of brachial-basilic arteriovenous fistula and prosthetic
brachial-antecubital forearm loop as vascular access for hemodialysis.
J Vasc Surg. 2008;47(2):395-401.
76. Woo K, Ulloa J, Allon M, et al. Establishing patient-specific
criteria for selecting the optimal upper extremity vascular access
procedure. J Vasc Surg. 2017;65(4):1089-1103 e1081.
77. Cheung AK, Imrey PB, Alpers CE, et al. Intimal Hyperplasia,
Stenosis, and Arteriovenous Fistula Maturation Failure in the Hemodialysis
Fistula Maturation Study. J Am Soc Nephrol.
2017;28(10):3005-3013.
78. Al-Jaishi AA, Oliver MJ, Thomas SM, et al. Patency rates of the
arteriovenous fistula for hemodialysis: a systematic review and metaanalysis.
Am J Kidney Dis. 2014;63(3):464-478.
79. Baracco R, Mattoo T, Jain A, Kapur G, Valentini RP. Reducing
central venous catheters in chronic hemodialysis–a commitment to
arteriovenous fistula creation in children. Pediatr Nephrol.
2014;29(10):2013-2020.
80. Ma A, Shroff R, Hothi D, et al. A comparison of arteriovenous
fistulas and central venous lines for long-term chronic haemodialysis.
Pediatr Nephrol. 2013;28(2):321-326.
81. Sheth RD, Brandt ML, Brewer ED, Nuchtern JG, Kale AS,
Goldstein SL. Permanent hemodialysis vascular access survival in
children and adolescents with end-stage renal disease. Kidney Int.
2002;62(5):1864-1869.
82. Oguzkurt L, Tercan F, Torun D, Yildirim T, Zumrutdal A,
Kizilkilic O. Impact of short-term hemodialysis catheters on the
central veins: a catheter venographic study. Eur J Radiol.
2004;52(3):293-299.
83. Foster BJ, Mitsnefes MM, Dahhou M, Zhang X, Laskin BL.
Changes in Excess mortality from end stage renal disease in the
United States from 1995 to 2013. Clin J Am Soc Nephrol.
2018;13(1):91-99.
84. Pisoni RL, Zepel L, Fluck R, et al. International differences in
the location and use of arteriovenous accesses created for hemodialysis:
results from the Dialysis Outcomes and Practice Patterns
Study (DOPPS). Am J Kidney Dis. 2017;71(4):469-478.
85. Koksoy C, Demirci RK, Balci D, Solak T, Kose SK. Brachiobasilic
versus brachiocephalic arteriovenous fistula: a prospective
randomized study. J Vasc Surg. 2009;49(1):171-177.e175.
86. Diskin CJ, Stokes TJ, Dansby LM, Radcliff L, Carter TB,
Lazenby A. The first fistula: influence of location on catheter use and
the influence of catheter use on maturation. Int Urol Nephrol.
2015;47(9):1571-1575.
87. Field M, MacNamara K, Bailey G, Jaipersad A, Morgan RH,
Pherwani AD. Primary patency rates of AV fistulas and the effect of
patient variables. J Vasc Access. 2008;9(1):45-50.
88. Masengu A, Maxwell AP, Hanko JB. Investigating clinical
predictors of arteriovenous fistula functional patency in a European
cohort. Clin Kidney J. 2016;9(1):142-147.
89. Masengu A, McDaid J, Maxwell AP, Hanko JB. Preoperative
radial artery volume flow is predictive of arteriovenous fistula outcomes.
J Vasc Surg. 2016;63(2):429-435.
90. Maya ID, O’Neal JC, Young CJ, Barker-Finkel J, Allon M.
Outcomes of brachiocephalic fistulas, transposed brachiobasilic
fistulas, and upper arm grafts. Clin J Am Soc Nephrol. 2009;4(1):
86-92.
91. Mestres G, Fontsere N, Garcia-Madrid C, Campelos P,
Maduell F, Riambau V. Intra-operative factors predicting 1-month
arteriovenous fistula thrombosis. J Vasc Access. 2012;13(2):193-
197.
92. Roozbeh J, Serati AR, Malekhoseini SA. Arteriovenous fistula
thrombosis in patients on regular hemodialysis: a report of 171 patients.
Archives of Iranian Medicine. 2006;9(1):26-32.
93. Shingarev R, Barker-Finkel J, Allon M. Association of hemodialysis
central venous catheter use with ipsilateral arteriovenous
vascular access survival. Am J Kidney Dis. 2012;60(6):983-989.
94. Wilmink T, Hollingworth L, Powers S, Allen C, Dasgupta I.
Natural history of common autologous arteriovenous fistulae: consequences
for planning of dialysis. Eur J Vasc Endovasc Surg.
2016;51(1):134-140.
95. Farber A, Tan TW, Hu B, et al. The effect of location and
configuration on forearm and upper arm hemodialysis arteriovenous
grafts. J Vasc Surg. 2015;62(5):1258-1265.
96. Dixon BS, Beck GJ, Vazquez MA, et al. Effect of dipyridamole
plus aspirin on hemodialysis graft patency. N Engl J Med.
2009;360(21):2191-2201.
97. Engstrom BI, Horvath JJ, Stewart JK, et al. Tunneled internal
jugular hemodialysis catheters: impact of laterality and tip position on
catheter dysfunction and infection rates. J Vasc Interv Radiol.
2013;24(9):1295-1302.
98. Shenoy S. Surgical anatomy of upper arm: what is needed for
AVF planning. J Vasc Access. 2009;10(4):223-232.
99. Johnson DCP, Healy JC, et al. Gray’s anatomic basis for
clinical practice. 40th Edition ed. Elsevier Churchill Livingstone;
2008.
100. Parienti JJ, Thirion M, Megarbane B, et al. Femoral vs jugular
venous catheterization and risk of nosocomial events in adults
requiring acute renal replacement therapy: a randomized controlled
trial. JAMA. 2008;299(20):2413-2422.
101. Marik PE, Flemmer M, Harrison W. The risk of catheterrelated
bloodstream infection with femoral venous catheters as
compared to subclavian and internal jugular venous catheters: a
systematic review of the literature and meta-analysis. Crit Care Med.
2012;40(8):2479-2485.
102. Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL.
Central venous access sites for the prevention of venous thrombosis,
stenosis and infection. Cochrane Database Syst Rev
2012;(3)Cd004084.
103. Okada S, Shenoy S. Arteriovenous access for hemodialysis:
preoperative assessment and planning. J Vasc Access.
2014;15(Suppl 7):S1-5.
104. Kordzadeh A, Chung J, Panayiotopoulos YP. Cephalic vein
and radial artery diameter in formation of radiocephalic arteriovenous
fistula: a systematic review. J Vasc Access. 2015;16(6):506-511.
105. Baker Jr LD, Johnson JM, Goldfarb D. Expanded polytetrafluoroethylene
(PTFE) subcutaneous arteriovenous conduit: an
improved vascular access for chronic hemodialysis. Trans Am Soc
Artif Intern Organs. 1976;22:382-387.
106. Barron PT, Wellington JL, Lorimer JW, Cole CW, Moher D.
A comparison between expanded polytetrafluoroethylene and
plasma tetrafluoroethylene grafts for hemodialysis access. Can J
Surg. 1993;36(2):184-186.
107. Helling TS, Nelson PW, Shelton L. A prospective evaluation
of plasma-TFE and expanded PTFE grafts for routine and early use
as vascular access during hemodialysis. Ann Surg. 1992;216(5):
596-599.
108. Glickman MH, Stokes GK, Ross JR, et al. Multicenter
evaluation of a polytetrafluoroethylene vascular access graft as
compared with the expanded polytetrafluoroethylene vascular access
graft in hemodialysis applications. J Vasc Surg. 2001;34(3):
465-472.
109. Ravari H, Kazemzade GH, Modaghegh MH, Khashayar P.
Patency rate and complications of polytetrafluoroethylene grafts
compared with polyurethane grafts for hemodialysis access. Ups J
Med Sci. 2010;115(4):245-248.
110. Hurlbert SN, Mattos MA, Henretta JP, et al. Long-term
patency rates, complications and cost-effectiveness of polytetrafluoroethylene
(PTFE) grafts for hemodialysis access: a prospective
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S149
study that compares Impra versus Gore-tex grafts. Cardiovasc Surg.
1998;6(6):652-656.
111. Kaufman JL, Garb JL, Berman JA, Rhee SW, Norris MA,
Friedmann P. A prospective comparison of two expanded polytetrafluoroethylene
grafts for linear forearm hemodialysis access:
does the manufacturer matter? J Am Coll Surg. 1997;185(1):
74-79.
112. Lenz BJ, Veldenz HC, Dennis JW, Khansarinia S,
Atteberry LR. A three-year follow-up on standard versus thin wall
ePTFE grafts for hemodialysis. J Vasc Surg. 1998;28(3):464-470.
113. Tordoir JH, Hofstra L, Leunissen KM, Kitslaar PJ. Early
experience with stretch polytetrafluoroethylene grafts for haemodialysis
access surgery: results of a prospective randomised study.
Eur J Vasc Endovasc Surg. 1995;9(3):305-309.
114. Dammers R, Planken RN, Pouls KP, et al. Evaluation of 4mm
to 7-mm versus 6-mm prosthetic brachial-antecubital forearm
loop access for hemodialysis: results of a randomized multicenter
clinical trial. J Vasc Surg. 2003;37(1):143-148.
115. Polo JR, Ligero JM, Diaz-Cartelle J, Garcia-Pajares R,
Cervera T, Reparaz L. Randomized comparison of 6-mm straight
grafts versus 6- to 8-mm tapered grafts for brachial-axillary dialysis
access. J Vasc Surg. 2004;40(2):319-324.
116. Ko PJ, Liu YH, Hung YN, Hsieh HC. Patency rates of cuffed
and noncuffed extended polytetrafluoroethylene grafts in dialysis
access: a prospective, randomized study. World J Surg. 2009;33(4):
846-851.
117. Sorom AJ, Hughes CB, McCarthy JT, et al. Prospective,
randomized evaluation of a cuffed expanded polytetrafluoroethylene
graft for hemodialysis vascular access. Surgery. 2002;132(2):135-
140.
118. Shemesh D, Goldin I, Hijazi J, et al. A prospective randomized
study of heparin-bonded graft (Propaten) versus standard graft
in prosthetic arteriovenous access. J Vasc Surg. 2015;62(1):115-
122.
119. Ko PJ, Hsieh HC, Chu JJ, Lin PJ, Liu YH. Patency rates and
complications of Exxcel yarn-wrapped polytetrafluoroethylene grafts
versus Gore-tex stretch polytetrafluoroethylene grafts: a prospective
study. Surg Today. 2004;34(5):409-412.
120. Aitken E, Thomson P, Bainbridge L, Kasthuri R, Mohr B,
Kingsmore D. A randomized controlled trial and cost-effectiveness
analysis of early cannulation arteriovenous grafts versus tunneled
central venous catheters in patients requiring urgent vascular access
for hemodialysis. J Vasc Surg. 2017;65(3):766-774.
121. Al SJ, Houston G, Inston N. Early cannulation grafts for
haemodialysis: a systematic review. J Vasc Access. 2019 Mar;20(2):
123-127.
122. Nassar GM, Glickman MH, McLafferty RB, et al.
A comparison between the HeRO graft and conventional arteriovenous
grafts in hemodialysis patients. Semin Dial. 2014;27(3):310-
318.
123. Kennealey PT, Elias N, Hertl M, et al. A prospective, randomized
comparison of bovine carotid artery and expanded polytetrafluoroethylene
for permanent hemodialysis vascular access.
J Vasc Surg. 2011;53(6):1640-1648.
124. Mousavi SR, Moatamedi MR, Me AM. Comparing frozen
saphenous vein with Gore-tex in vascular access for chronic hemodialysis.
Hemodial Int. 2011;15(4):559-562.
125. Huber TS, Hirneise CM, Lee WA, Flynn TC, Seeger JM.
Outcome after autogenous brachial-axillary translocated superficial
femoropopliteal vein hemodialysis access. J Vasc Surg. 2004;40(2):
311-318.
126. Illig KA, Orloff M, Lyden SP, Green RM. Transposed
saphenous vein arteriovenous fistula revisited: new technology for an
old idea. Cardiovasc Surg. 2002;10(3):212-215.
127. Robbin ML, Chamberlain NE, Lockhart ME, et al. Hemodialysis
arteriovenous fistula maturity: US evaluation. Radiology.
2002;225(1):59-64.
128. Hertzberg BS, Kliewer MA, DeLong DM, et al. Sonographic
assessment of lower limb vein diameters: implications for the diagnosis
and characterization of deep venous thrombosis. AJR Am J
Roentgenol. 1997;168(5):1253-1257.
129. Rajan DK, Ebner A, Desai SB, Rios JM, Cohn WE. Percutaneous
creation of an arteriovenous fistula for hemodialysis access.
J Vasc Interv Radiol. 2015;26(4):484-490.
130. Gage SM, Lawson JH. Bioengineered hemodialysis access
grafts. J Vasc Access. 2017;18(Suppl. 1):56-63.
131. Power A, Hill P, Singh SK, Ashby D, Taube D, Duncan N.
Comparison of Tesio and LifeCath twin permanent hemodialysis
catheters: the VyTes randomized trial. J Vasc Access. 2014;15(2):
108-115.
132. Van Der Meersch H, De Bacquer D, Vandecasteele SJ, et al.
Hemodialysis catheter design and catheter performance: a randomized
controlled trial.[Erratum appears in Am J Kidney Dis. 2015
May;65(5):810]. Am J Kidney Dis. 2014;64(6):902-908.
133. Hwang HS, Kang SH, Choi SR, Sun IO, Park HS, Kim Y.
Comparison of the palindrome vs. step-tip tunneled hemodialysis
catheter: a prospective randomized trial. Semin Dial. 2012;25(5):
587-591.
134. O’Dwyer H, Fotheringham T, O’Kelly P, et al. A prospective
comparison of two types of tunneled hemodialysis catheters: the
Ash Split versus the PermCath. Cardiovasc Intervent Radiol.
2005;28(1):23-29.
135. Trerotola SO, Kraus M, Shah H, et al. Randomized comparison
of split tip versus step tip high-flow hemodialysis catheters.
Kidney Int. 2002;62(1):282-289.
136. Al-Balas A, Lee T, Young CJ, Barker-Finkel J, Allon M. Predictors
of Initiation for Predialysis Arteriovenous Fistula. Clin J Am
Soc Nephrol. 2016;11(10):1802-1808.
137. Shechter SM, Skandari MR, Zalunardo N. Timing of arteriovenous
fistula creation in patients With CKD: a decision analysis.
Am J Kidney Dis. 2014;63(1):95-103.
138. Hod T, Patibandla BK, Vin Y, Brown RS, GoldfarbRumyantzev
AS. Arteriovenous fistula placement in the elderly: when
is the optimal time? J Am Soc Nephrol. 2015;26(2):448-456.
139. US Renal Data System. Chapter 3: vascular access. In:
USRDS 2017 Annual Data Report: Atlas of Chronic Kidney Disease
and End-Stage Renal Disease in the United States. Bethesda,
MD: National Institutes of Health; 2017.
140. Al-Jaishi AA, Jain AK, Garg AX, Zhang JC, Moist LM. Hemodialysis
vascular access creation in patients switching from
peritoneal dialysis to hemodialysis: a population-based retrospective
cohort. Am J Kidney Dis. 2016;67(5):813-816.
141. Kidney Failure Risk Calculator. https://kidneyfailurerisk.
com/.
142. McGill RL, Ruthazer R, Meyer KB, Miskulin DC, Weiner DE.
Peripherally Inserted Central Catheters and Hemodialysis Outcomes.
Clin J Am Soc Nephrol. 2016;11(8):1434-1440.
143. Shingarev R, Allon M. Peripherally inserted central catheters
and other intravascular devices: how safe are they for hemodialysis
patients? Am J Kidney Dis. 2012;60(4):510-513.
144. El Ters M, Schears GJ, Taler SJ, et al. Association between
prior peripherally inserted central catheters and lack of functioning
arteriovenous fistulas: a case-control study in hemodialysis patients.
Am J Kidney Dis. 2012;60(4):601-608.
145. Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N,
Bonn J. Incidence of central vein stenosis and occlusion following
upper extremity PICC and port placement. Cardiovasc Intervent
Radiol. 2003;26(2):123-127.
References
S150 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
146. Itkin M, Mondshein JI, Stavropoulos SW, ShlanskyGoldberg
RD, Soulen MC, Trerotola SO. Peripherally inserted central
catheter thrombosis—reverse tapered versus nontapered catheters:
a randomized controlled study. J Vasc Interv Radiol.
2014;25(1):85-91.e81.
147. McGill RL, Tsukahara T, Bhardwaj R, Kapetanos AT,
Marcus RJ. Inpatient venous access practices: PICC culture and the
kidney patient. J Vasc Access. 2015;16(3):206-210.
148. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post
catheterisation vein stenosis in haemodialysis: comparative angiographic
study of 50 subclavian and 50 internal jugular accesses.
Nephrol Dial Transplant. 1991;6(10):722-724.
149. Winters JP, Callas PW, Cushman M, Repp AB, Zakai NA.
Central venous catheters and upper extremity deep vein thrombosis
in medical inpatients: the Medical Inpatients and Thrombosis (MITH)
Study. J Thromb Haemost. 2015;13(12):2155-2160.
150. Sakhuja R, Keebler M, Lai TS, McLaughlin Gavin C,
Thakur R, Bhatt DL. Meta-analysis of mortality in dialysis patients
with an implantable cardioverter defibrillator. Am J Cardiol.
2009;103(5):735-741.
151. Saad TF, Hentschel DM, Koplan B, et al. Cardiovascular
implantable electronic device leads in CKD and ESRD patients:
review and recommendations for practice. Semin Dial. 2013;26(1):
114-123.
152. Dhamija RK, Tan H, Philbin E, et al. Subcutaneous
implantable cardioverter defibrillator for dialysis patients: a strategy
to reduce central vein stenoses and infections. Am J Kidney Dis.
2015;66(1):154-158.
153. Da Costa A, Axiotis A, Romeyer-Bouchard C, et al. Transcatheter
leadless cardiac pacing: The new alternative solution. Int J
Cardiol. 2017;227:122-126.
154. Rashid M, Kwok CS, Pancholy S, et al. Radial artery occlusion
after transradial interventions: a systematic review and metaanalysis.
J Am Heart Assoc. 2016;5(1).
155. Vassalotti JA, Falk A, Teodorescu V, Uribarri J. The multidisciplinary
approach to hemodialysis vascular access at the Mount
Sinai Hospital. Mt Sinai J Med. 2004;71(2):94-102.
156. Vassalotti JA, Jennings WC, Beathard GA, et al. Fistula First
breakthrough initiative: targeting Catheter Last in Fistula First. Semin
Dial. 2012;25(3):303-310.
157. Kimmel PL, Peterson RA, Weihs KL, et al. Aspects of quality
of life in hemodialysis patients. J Am Soc Nephrol. 1995;6(5):1418-
1426.
158. Allon M, Imrey PB, Cheung AK, et al. Relationships between
clinical processes and arteriovenous fistula cannulation and maturation:
a multicenter prospective cohort study. Am J Kidney Dis.
2018;71(5):677-689.
159. Cavanaugh KL, Wingard RL, Hakim RM, Elasy TA, Ikizler TA.
Patient dialysis knowledge is associated with permanent arteriovenous
access use in chronic hemodialysis. Clin J Am Soc Nephrol.
2009;4(5):950-956.
160. Fenton A, Sayar Z, Dodds A, Dasgupta I. Multidisciplinary
care improves outcome of patients with stage 5 chronic kidney
disease. Nephron Clin Pract. 2010;115(4):c283-c288.
161. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association
between multidisciplinary care and survival for elderly patients with
chronic kidney disease. J Am Soc Nephrol. 2007;18(3):993-999.
162. Lacson Jr E, Wang W, DeVries C, et al. Effects of a
nationwide predialysis educational program on modality choice,
vascular access, and patient outcomes. Am J Kidney Dis.
2011;58(2):235-242.
163. Lei CC, Lee PH, Hsu YC, et al. Educational intervention in
CKD retards disease progression and reduces medical costs for
patients with stage 5 CKD. Renal Failure. 2013;35(1):9-16.
164. Wei SY, Chang YY, Mau LW, et al. Chronic kidney disease
care program improves quality of pre-end-stage renal disease care
and reduces medical costs. Nephrology. 2010;15(1):108-115.
165. Wilson SM, Robertson JA, Chen G, et al. The IMPACT
(Incident Management of Patients, Actions Centered on Treatment)
program: a quality improvement approach for caring for patients
initiating long-term hemodialysis. Am J Kidney Dis. 2012;60(3):435-
443.
166. Wingard RL, Chan KE, Lazarus JM, Hakim RM. The "right"
of passage: surviving the first year of dialysis. Clin J Am Soc
Nephrol. 2009;4(Suppl 1):S114-120.
167. Wingard RL, Pupim LB, Krishnan M, Shintani A, Ikizler TA,
Hakim RM. Early intervention improves mortality and hospitalization
rates in incident hemodialysis patients: RightStart program. Clin J
Am Soc Nephrol. 2007;2(6):1170-1175.
168. Polkinghorne KR, Seneviratne M, Kerr PG. Effect of a
vascular access nurse coordinator to reduce central venous catheter
use in incident hemodialysis patients: a quality improvement
report. Am J Kidney Dis. 2009;53(1):99-106.
169. Wu IW, Wang SY, Hsu KH, et al. Multidisciplinary predialysis
education decreases the incidence of dialysis and reduces mortality–a
controlled cohort study based on the NKF/DOQI guidelines.
Nephrol Dial Transplant. 2009;24(11):3426-3433.
170. Pisoni RL, Zepel L, Port FK, Robinson BM. Trends in US
vascular access use, patient preferences, and related practices: an
update from the US DOPPS practice monitor with international
comparisons. Am J Kidney Dis. 2015;65(6):905-915.
171. Lok CE, Foley R. Vascular access morbidity and mortality:
trends of the last decade. Clin J Am Soc Nephrol. 2013;8(7):1213-
1219.
172. Kiaii M, MacRae JM. A dedicated vascular access program
can improve arteriovenous fistula rates without increasing catheters.
J Vasc Access. 2008;9(4):254-259.
173. Mbamalu G, Whiteman K. Vascular access team collaboration
to decrease catheter rates in patients on hemodialysis: utilization
of Kotter’s change process. Nephrol Nurs J. 2014;41(3):283-287.
quiz 288.
174. Gill S, Quinn R, Oliver M, et al. Multi-disciplinary vascular
access care and access outcomes in people starting hemodialysis
therapy. Clin J Am Soc Nephrol. 2017;12(12):1991-1999.
175. Dwyer A, Shelton P, Brier M, Aronoff G. A vascular access
coordinator improves the prevalent fistula rate. Semin Dial.
2012;25(2):239-243.
176. Kalman PG, Pope M, Bhola C, Richardson R,
Sniderman KW. A practical approach to vascular access for hemodialysis
and predictors of success. J Vasc Surg. 1999;30(4):727-
733.
177. Mokrzycki MH, Zhang M, Golestaneh L, Laut J,
Rosenberg SO. An interventional controlled trial comparing 2 management
models for the treatment of tunneled cuffed catheter
bacteremia: a collaborative team model versus usual physicianmanaged
care. Am J Kidney Dis. 2006;48(4):587-595.
178. Inrig JK, Sun JL, Yang Q, Briley LP, Szczech LA. Mortality by
dialysis modality among patients who have end-stage renal disease
and are awaiting renal transplantation. Clin J Am Soc Nephrol.
2006;1(4):774-779.
179. Ramanathan V, Chiu EJ, Thomas JT, Khan A, Dolson GM,
Darouiche RO. Healthcare costs associated with hemodialysis
catheter-related infections: a single-center experience. Infect Control
Hosp Epidemiol. 2007;28(5):606-609.
180. Ferring M, Claridge M, Smith SA, Wilmink T. Routine preoperative
vascular ultrasound improves patency and use of arteriovenous
fistulas for hemodialysis: a randomized trial. Clin J Am Soc
Nephrol. 2010;5(12):2236-2244.
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S151
181. Nursal TZ, Oguzkurt L, Tercan F, et al. Is routine preoperative
ultrasonographic mapping for arteriovenous fistula creation necessary
in patients with favorable physical examination findings? Results
of a randomized controlled trial. World J Surg. 2006;30(6):1100-
1107.
182. Yaghoubian A, Lewis RJ, de Virgilio C. Can the National
Kidney Foundation guidelines for first-time arteriovenous fistula
creation be met in underserved end-stage renal disease patients?
Ann Vasc Surg. 2008;22(1):5-10.
183. Smith GE, Barnes R, Chetter IC. Randomized clinical trial of
selective versus routine preoperative duplex ultrasound imaging
before arteriovenous fistula surgery. Br J Surg. 2014;101(5):469-
474.
184. Silva Jr MB, Hobson 2nd RW, Pappas PJ, et al. A strategy
for increasing use of autogenous hemodialysis access procedures:
impact of preoperative noninvasive evaluation. J Vasc Surg.
1998;27(2):302-307. discussion 307-308.
185. Mendes RR, Farber MA, Marston WA, Dinwiddie LC,
Keagy BA, Burnham SJ. Prediction of wrist arteriovenous fistula
maturation with preoperative vein mapping with ultrasonography.
J Vasc Surg. 2002;36(3):460-463.
186. Feldman HI, Joffe M, Rosas SE, Burns JE, Knauss J,
Brayman K. Predictors of successful arteriovenous fistula maturation.
Am J Kidney Dis. 2003;42(5):1000-1012.
187. Lockhart ME, Robbin ML, Fineberg NS, Wells CG, Allon M.
Cephalic vein measurement before forearm fistula creation: does
use of a tourniquet to meet the venous diameter threshold increase
the number of usable fistulas? J Ultrasound Med. 2006;25(12):
1541-1545.
188. Dageforde LA, Harms KA, Feurer ID, Shaffer D. Increased
minimum vein diameter on preoperative mapping with duplex ultrasound
is associated with arteriovenous fistula maturation and secondary
patency. J Vasc Surg. 2015;61(1):170-176.
189. Malovrh M. Native arteriovenous fistula: preoperative evaluation.
Am J Kidney Dis. 2002;39(6):1218-1225.
190. Lee C. Anesthesia for vascular access surgery in renal
failure. In: Wilson S, ed. Vascular access surgery. Chicago: Year
Book Medical Publishers; 1988:153-173.
191. Mouquet C, Bitker MO, Bailliart O, et al. Anesthesia for
creation of a forearm fistula in patients with endstage renal failure.
Anesthesiology. 1989;70(6):909-914.
192. Sahin L, Gul R, Mizrak A, et al. Ultrasound-guided
infraclavicular brachial plexus block enhances postoperative
blood flow in arteriovenous fistulas. J Vasc Surg. 2011;54(3):
749-753.
193. Rooijens PP, Tordoir JH, Stijnen T, Burgmans JP, Smet
de AA, Yo TI. Radiocephalic wrist arteriovenous fistula for hemodialysis:
meta-analysis indicates a high primary failure rate. Eur J Vasc
Endovasc Surg. 2004;28(6):583-589.
194. Schenk 3rd WG. Improving dialysis access: regional anesthesia
improves arteriovenous fistula prevalence. Am Surg.
2010;76(9):938-942.
195. Shemesh D, Olsha O, Orkin D, et al. Sympathectomy-like
effects of brachial plexus block in arteriovenous access surgery.
Ultrasound Med Biol. 2006;32(6):817-822.
196. Malinzak EB, Gan TJ. Regional anesthesia for vascular access
surgery. Anesth Anal. 2009;109(3):976-980.
197. Marhofer P, Harrop-Griffiths W, Willschke H, Kirchmair L.
Fifteen years of ultrasound guidance in regional anaesthesia: part
2—recent developments in block techniques. BJA: Br J Anaesth.
2010;104(6):673-683.
198. Aitken E, Jackson A, Kearns R, et al. Effect of regional
versus local anaesthesia on outcome after arteriovenous fistula
creation: a randomised controlled trial. Lancet. 2016;388(10049):
1067-1074.
199. Lo Monte AI, Damiano G, Mularo A, et al. Comparison between
local and regional anesthesia in arteriovenous fistula creation.
J Vasc Access. 2011;12(4):331-335.
200. Meena S, Arya V, Sen I, Minz M, Prakash M. Ultrasoundguided
supraclavicular brachial plexus anaesthesia improves arteriovenous
fistula flow characteristics in end-stage renal disease
patients. South Afr J Anaesth Anal. 2015;21(5):12-15.
201. Yildirim V, Doganci S, Yanarates O, et al. Does preemptive
stellate ganglion blockage increase the patency of radiocephalic
arteriovenous fistula? Scand Cardiovasc J. 2006;40(6):380-384.
202. Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity
regional anesthesia: essentials of our current understanding, 2008.
Reg Anesth Pain Med. 2009;34(2):134-170.
203. Robbin ML, Greene T, Cheung AK, et al. Arteriovenous
fistula development in the first 6 weeks after creation. Radiology.
2016;279(2):620-629.
204. Ojha M, Cobbold RS, Johnston KW. Influence of angle on
wall shear stress distribution for an end-to-side anastomosis. J Vasc
Surg. 1994;19(6):1067-1073.
205. Staalsen NH, Ulrich M, Winther J, Pedersen EM, How T,
Nygaard H. The anastomosis angle does change the flow fields at
vascular end-to-side anastomoses in vivo. J Vasc Surg. 1995;21(3):
460-471.
206. Hofstra L, Bergmans DC, Leunissen KM, et al. Anastomotic
intimal hyperplasia in prosthetic arteriovenous fistulas for hemodialysis
is associated with initial high flow velocity and not with mismatch
in elastic properties. J Am Soc Nephrol. 1995;6(6):1625-1633.
207. Badero OJ, Salifu MO, Wasse H, Work J. Frequency of
swing-segment stenosis in referred dialysis patients with angiographically
documented lesions. Am J Kidney Dis. 2008;51(1):93-
98.
208. Ene-Iordache B, Cattaneo L, Dubini G, Remuzzi A. Effect of
anastomosis angle on the localization of disturbed flow in ’side-toend’
fistulae for haemodialysis access. Nephrol Dial Transplant.
2013;28(4):997-1005.
209. Bharat A, Jaenicke M, Shenoy S. A novel technique of
vascular anastomosis to prevent juxta-anastomotic stenosis
following arteriovenous fistula creation. J Vasc Surg. 2012;55(1):
274-280.
210. Mozaffar M, Fallah M, Lotfollahzadeh S, et al. Comparison of
efficacy of side to side versus end to side arteriovenous fistulae
formation in chronic renal failure as a permanent hemodialysis access.
Nephrourology Monthly. 2013;5(3):827-830.
211. Sadaghianloo N, Declemy S, Jean-Baptiste E, et al. Radial
artery deviation and reimplantation inhibits venous juxta-anastomotic
stenosis and increases primary patency of radial-cephalic fistulas for
hemodialysis. J Vasc Surg. 2016;64(3):698-706.e691.
212. Shenoy S. Surgical technique determines the outcome of
the Brescia/Cimino AVF. J Vasc Access. 2017;18(Suppl. 1):1-4.
213. Ene-Iordache B, Mosconi L, Remuzzi G, Remuzzi A.
Computational fluid dynamics of a vascular access case for hemodialysis.
J Biomech Eng. 2001;123(3):284-292.
214. Darcy M, Vachharajani N, Zhang T, et al. Long-term outcome
of upper extremity arteriovenous fistula using pSLOT: single-center
longitudinal follow-up using a protocol-based approach. J Vasc Access.
2017;18(6):515-521.
215. Bronder CM, Cull DL, Kuper SG, et al. Fistula elevation
procedure: experience with 295 consecutive cases during a 7-year
period. J Am Coll Surg. 2008;206(5):1076-1081.
216. Bourquelot P, Tawakol JB, Gaudric J, et al. Lipectomy as a
new approach to secondary procedure superficialization of direct
autogenous forearm radial-cephalic arteriovenous accesses for hemodialysis.
J Vasc Surg. 2009;50(2):369-374. 374.e361.
217. Inkollu S, Wellen J, Beller Z, Zhang T, Vachharajani N,
Shenoy S. Successful use of minimal incision superficialization
References
S152 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
technique for arteriovenous fistula maturation. J Vasc Surg.
2016;63(4):1018-1025.
218. Galt S, Crawford M, Blebea J, Ladenheim E, Browne B. The
efficacy and durability of the Venous Window Needle Guide
implanted on uncannulatable arteriovenous fistulas. J Vasc Surg.
2016;64(3):708-714.
219. Miles Maliska 3rd C, Jennings W, Mallios A. When Arteriovenous
Fistulas Are Too Deep: Options in Obese Individuals. J Am
Coll Surg. 2015;221(6):1067-1072.
220. Barnard KJ, Taubman KE, Jennings WC. Accessible
autogenous vascular access for hemodialysis in obese individuals
using lipectomy. Am J Surg. 2010;200(6):798-802.
221. Stoikes N, Nezakatgoo N, Fischer P, Bahr M, Magnotti L.
Salvage of inaccessible arteriovenous fistulas in obese patients: a
review of 132 brachiocephalic fistulas. Am Surg. 2009;75(8):705-
709.
222. Ene-Iordache B, Remuzzi A. Disturbed flow in radialcephalic
arteriovenous fistulae for haemodialysis: low and oscillating
shear stress locates the sites of stenosis. Nephrol Dial
Transplant. 2012;27(1):358-368.
223. Hull JE, Balakin BV, Kellerman BM, Wrolstad DK.
Computational fluid dynamic evaluation of the side-to-side anastomosis
for arteriovenous fistula. J Vasc Surg. 2013;58(1):187-
193 e181.
224. Baguneid MS, Goldner S, Fulford PE, Hamilton G,
Walker MG, Seifalian AM. A comparison of para-anastomotic
compliance profiles after vascular anastomosis: nonpenetrating
clips versus standard sutures. J Vasc Surg. 2001;33(4):812-820.
225. Kirsch WM, Zhu YH, Hardesty RA, Chapolini R. A new
method for microvascular anastomosis: report of experimental and
clinical research. Am Surg. 1992;58(12):722-727.
226. Ross JR. Creation of native arteriovenous fistulas with
interrupted anastomoses using a self-closing clip device - one
clinic’s experience. J Vasc Access. 2002;3(4):140-146.
227. Aitken E, Jeans E, Aitken M, Kingsmore D. A randomized
controlled trial of interrupted versus continuous suturing techniques
for radiocephalic fistulas. J Vasc Surg. 2015;62(6):1575-1582.
228. Nguyen KP, Teruya T, Alabi O, et al. Comparison of Nonpenetrating
Titanium Clips versus Continuous Polypropylene Suture
in Dialysis Access Creation. Ann Vasc Surg. 2016;32:15-19.
229. Zeebregts CJ, van den Dungen JJ, van Det RJ,
Verhoeven EL, Geelkerken RH, van Schilfgaarde R. Randomized
clinical trial of continuous sutures or non-penetrating clips for radiocephalic
arteriovenous fistula. Br J Surg. 2004;91(11):1438-1442.
230. Walker SR. U Clips for arteriovenous anastomosis: a pilot,
randomized study. ANZ J Surg. 2012;82(9):630-632.
231. Shenoy S, Miller A, Petersen F, et al. A multicenter study of
permanent hemodialysis access patency: beneficial effect of clipped
vascular anastomotic technique. J Vasc Surg. 2003;38(2):229-235.
232. Berdat PA, Lavanchy JL, Schonhoff F, Pavlovic M,
Pfammatter JP, Carrel TP. Growth potential of U-clip interrupted
versus polypropylene running suture anastomosis in congenital
cardiac surgery: intermediate term results. Interact Cardiovasc
Thorac Surg. 2009;9(4):565-570.
233. Allon M. Current management of vascular access. Clin J Am
Soc Nephrol. 2007;2(4):786-800.
234. Allon M, Robbin ML. Increasing arteriovenous fistulas in
hemodialysis patients: problems and solutions. Kidney Int.
2002;62(4):1109-1124.
235. Miller CD, Robbin ML, Barker J, Allon M. Comparison of
arteriovenous grafts in the thigh and upper extremities in hemodialysis
patients. J Am Soc Nephrol. 2003;14(11):2942-2947.
236. Miller PE, Carlton D, Deierhoi MH, Redden DT, Allon M.
Natural history of arteriovenous grafts in hemodialysis patients. Am J
Kidney Dis. 2000;36(1):68-74.
237. Beathard GA. Percutaneous transvenous angioplasty in the
treatment of vascular access stenosis. Kidney Int. 1992;42(6):
1390-1397.
238. Lilly RZ, Carlton D, Barker J, et al. Predictors of arteriovenous
graft patency after radiologic intervention in hemodialysis patients.
Am J Kidney Dis. 2001;37(5):945-953.
239. Maya ID, Oser R, Saddekni S, Barker J, Allon M. Vascular
access stenosis: comparison of arteriovenous grafts and fistulas.
Am J Kidney Dis. 2004;44(5):859-865.
240. Conte MS, Nugent HM, Gaccione P, Guleria I, RoyChaudhury
P, Lawson JH. Multicenter phase I/II trial of the safety of
allogeneic endothelial cell implants after the creation of arteriovenous
access for hemodialysis use: the V-HEALTH study. J Vasc
Surg. 2009;50(6):1359-1368.e1351.
241. Conte MS, Nugent HM, Gaccione P, Roy-Chaudhury P,
Lawson JH. Influence of diabetes and perivascular allogeneic
endothelial cell implants on arteriovenous fistula remodeling. J Vasc
Surg. 2011;54(5):1383-1389.
242. Hye RJ, Peden EK, O’Connor TP, et al. Human type I
pancreatic elastase treatment of arteriovenous fistulas in patients
with chronic kidney disease. J Vasc Surg. 2014;60(2):454-461.
e451.
243. Peden EK, Leeser DB, Dixon BS, et al. A multi-center, doseescalation
study of human type I pancreatic elastase (PRT-201)
administered after arteriovenous fistula creation. J Vasc Access.
2013;14(2):143-151.
244. Dwivedi AJ, Roy-Chaudhury P, Peden EK, et al. Application
of human type I pancreatic elastase (PRT-201) to the venous
anastomosis of arteriovenous grafts in patients with chronic kidney
disease. J Vasc Access. 2014;15(5):376-384.
245. Nikam M, Chemla ES, Evans J, et al. Prospective controlled
pilot study of arteriovenous fistula placement using the novel Optiflow
device. J Vasc Surg. 2015;61(4):1020-1025.
246. Chemla E, Tavakoli A, Nikam M, et al. Arteriovenous fistula
creation using the Optiflow vascular anastomotic connector: the
OPEN (Optiflow PatEncy and MaturatioN) study. J Vasc Access.
2014;15(1):38-44.
247. Syed FA, Smolock CJ, Duran C, et al. Comparison of outcomes
of one-stage basilic vein transpositions and two-stage basilic
vein transpositions. Ann Vasc Surg. 2012;26(6):852-857.
248. Cooper J, Power AH, DeRose G, Forbes TL, Dubois L.
Similar failure and patency rates when comparing one- and twostage
basilic vein transposition. J Vasc Surg. 2015;61(3):809-816.
249. De Marco Garcia LP, Davila-Santini LR, Feng Q, Calderin J,
Krishnasastry KV, Panetta TF. Primary balloon angioplasty plus
balloon angioplasty maturation to upgrade small-caliber veins (<3
mm) for arteriovenous fistulas. J Vasc Surg. 2010;52(1):139-144.
250. Yevzlin AS, Song GU, Sanchez RJ, Becker YT. Fluoroscopically
guided vs modified traditional placement of tunneled hemodialysis
catheters: clinical outcomes and cost analysis. J Vasc
Access. 2007;8(4):245-251.
251. Maecken T, Marcon C, Bomas S, Zenz M, Grau T. Relationship
of the internal jugular vein to the common carotid artery:
implications for ultrasound-guided vascular access. Eur J Anaesthesiol.
2011;28(5):351-355.
252. Troianos CA, Kuwik RJ, Pasqual JR, Lim AJ, Odasso DP.
Internal jugular vein and carotid artery anatomic relation as determined
by ultrasonography. Anesthesiology. 1996;85(1):43-48.
253. Prabhu MV, Juneja D, Gopal PB, et al. Ultrasound-guided
femoral dialysis access placement: a single-center randomized trial.
Clin J Am Soc Nephrol. 2010;5(2):235-239.
254. Hourmozdi JJ, Markin A, Johnson B, Fleming PR, Miller JB.
Routine chest radiography is not necessary after ultrasound-guided
right internal jugular vein catheterization. Crit Care Med.
2016;44(9):e804-e808.
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S153
255. Pikwer A, Baath L, Davidson B, Perstoft I, Akeson J. The
incidence and risk of central venous catheter malpositioning: a
prospective cohort study in 1619 patients. Anaesth Intensive Care.
2008;36(1):30-37.
256. Nazarian GK, Bjarnason H, Dietz Jr CA, Bernadas CA,
Hunter DW. Changes in tunneled catheter tip position when a patient
is upright. J Vasc Interv Radiol. 1997;8(3):437-441.
257. Clark E, Barsuk JH, Karpinski J, McQuillan R. Achieving
procedural competence during nephrology fellowship training: current
requirements and educational research. Clin J Am Soc Nephrol.
2016;11(12):2244-2249.
258. christiemed.com CMH. Vein Viewer. In:2018.
259. Phipps K, Modic A, O’Riordan MA, Walsh M. A randomized
trial of the Vein Viewer versus standard technique for placement of
peripherally inserted central catheters (PICCs) in neonates.
J Perinatol. 2012;32(7):498-501.
260. Zibari GB, Rohr MS, Landreneau MD, et al. Complications
from permanent hemodialysis vascular access. Surgery.
1988;104(4):681-686.
261. MacRae JM, Dipchand C, Oliver M, et al. Arteriovenous
access: infection, neuropathy, and other complications. Can J Kidney
Health Dis. 2016;3. 2054358116669127.
262. Ryan SV, Calligaro KD, Scharff J, Dougherty MJ. Management
of infected prosthetic dialysis arteriovenous grafts. J Vasc
Surg. 2004;39(1):73-78.
263. Leon C, Asif A. Arteriovenous Access and Hand Pain: The
distal hypoperfusion ischemic syndrome. Clin J Am Soc Nephrol.
2007;2(1):175-183.
264. Padberg Jr FT, Calligaro KD, Sidawy AN. Complications of
arteriovenous hemodialysis access: recognition and management.
J Vasc Surg. 2008;48(5 Suppl):55S-80S.
265. Suding PN, Wilson SE. Strategies for management of
ischemic steal syndrome. Semin Vasc Surg. 2007;20(3):184-188.
266. Agarwal AK. Central vein stenosis. Am J Kidney Dis.
2013;61(6):1001-1015.
267. Asif A, Leon C, Orozco-Vargas LC, et al. Accuracy of
physical examination in the detection of arteriovenous fistula stenosis.
Clin J Am Soc Nephrol. 2007;2(6):1191-1194.
268. Ferring M, Henderson J, Wilmink T. Accuracy of early postoperative
clinical and ultrasound examination of arteriovenous
fistulae to predict dialysis use. J Vasc Access. 2014;15(4):291-297.
269. Maldonado-Carceles AB, Garcia-Medina J, TorresCantero
AM. Performance of physical examination versus ultrasonography
to detect stenosis in haemodialysis arteriovenous fistula.
J Vasc Access. 2017;18(1):30-34.
270. AVF Quick Reference.
271. Vascular access monitoring. https://esrdncc.org/
contentassets/38ed6dc1892d46aeb6ccf51d96f025b0/121.staffcomplete-guide_508.pdf.
2019.
272. Wong V, Ward R, Taylor J, Selvakumar S, How TV, Bakran A.
Factors associated with early failure of arteriovenous fistulae for
haemodialysis access. Eur J Vasc Endovasc Surg. 1996;12(2):207-
213.
273. Zhu YL, Ding H, Fan PL, Gu QL, Teng J, Wang WP. Predicting
the maturity of haemodialysis arteriovenous fistulas with
colour Doppler ultrasound: a single-centre study from China. Clin
Radiol. 2016;71(6):576-582.
274. Fontsere N, Mestres G, Yugueros X, et al. Effect of a
postoperative exercise program on arteriovenous fistula maturation:
a randomized controlled trial. Hemodial Int. 2016;20(2):306-
314.
275. Salimi F, Majd Nassiri G, Moradi M, et al. Assessment of
effects of upper extremity exercise with arm tourniquet on maturity of
arteriovenous fistula in hemodialysis patients. J Vasc Access.
2013;14(3):239-244.
276. Bhomi KK, Shrestha S, Bhattachan CL. Role of systemic
anticoagulation in patients undergoing vascular access surgery.
Nepal Medical College Journal: NMCJ. 2008;10(4):222-224.
277. Chen L, Ling YS, Lin CH, Guan TJ. Combined use of heparin
and anisodamine reduces the risk of early thrombosis in native
arteriovenous fistula. Vascular. 2013;21(6):369-374.
278. D’Ayala M, Smith RM, Martone C, Briggs W, Deitch JS,
Wise L. The effect of systemic anticoagulation in patients undergoing
angioaccess surgery. Ann Vasc Surg. 2008;22(1):11-15.
279. Wang BR, Rowe VL, Ham SW, et al. A prospective clinical
evaluation of the effects of intraoperative systemic anticoagulation in
patients undergoing arteriovenous fistula surgery. Am Surg.
2010;76(10):1112-1114.
280. Ghorbani A, Aalamshah M, Shahbazian H, Ehsanpour A,
Aref A. Randomized controlled trial of clopidogrel to prevent primary
arteriovenous fistula failure in hemodialysis patients. Indian J
Nephrol. 2009;19(2):57-61.
281. Field M, McGrogan D, Marie Y, et al. Randomized clinical
trial of the use of glyceryl trinitrate patches to aid arteriovenous fistula
maturation. Br J Surg. 2016;103(10):1269-1275.
282. Wasse H, Huang R, Long Q, et al. Very high-dose cholecalciferol
and arteriovenous fistula maturation in ESRD: a randomized,
double-blind, placebo-controlled pilot study. J Vasc Access.
2014;15(2):88-94.
283. Abacilar AF, Atalay H, Dogan OF. Oral prostacycline analog
and clopidogrel combination provides early maturation and long-term
survival after arteriovenous fistula creation: A randomized controlled
study. Indian J Nephrol. 2015;25(3):136-142.
284. Tessitore N, Mansueto G, Lipari G, et al. Endovascular
versus surgical preemptive repair of forearm arteriovenous fistula
juxta-anastomotic stenosis: analysis of data collected prospectively
from 1999 to 2004. Clin J Am Soc Nephrol. 2006;1(3):448-454.
285. Ito Y, Sato T, Okada R, et al. Comparison of clinical effectiveness
between surgical and endovascular treatment for thrombotic
obstruction in hemodialysis access. J Vasc Access.
2011;12(1):63-66.
286. Lee T, Tindni A, Roy-Chaudhury P. Improved cumulative
survival in fistulas requiring surgical interventions to promote fistula
maturation compared with endovascular interventions. Semin Dial.
2013;26(1):85-89.
287. Lee T, Ullah A, Allon M, et al. Decreased cumulative access
survival in arteriovenous fistulas requiring interventions to promote
maturation. Clin J Am Soc Nephrol. 2011;6(3):575-581.
288. Long B, Brichart N, Lermusiaux P, et al. Management of
perianastomotic stenosis of direct wrist autogenous radial-cephalic
arteriovenous accesses for dialysis. J Vasc Surg. 2011;53(1):108-
114.
289. Miller GA, Goel N, Khariton A, et al. Aggressive approach to
salvage non-maturing arteriovenous fistulae: a retrospective study
with follow-up. J Vasc Access. 2009;10(3):183-191.
290. Miller GA, Hwang W, Preddie D, Khariton A, Savransky Y.
Percutaneous salvage of thrombosed immature arteriovenous fistulas.
Semin Dial. 2011;24(1):107-114.
291. Weijmer MC, Vervloet MG, ter Wee PM. Compared to
tunnelled cuffed haemodialysis catheters, temporary untunnelled
catheters are associated with more complications already within 2
weeks of use. Nephrol Dial Transplant. 2004;19(3):670-677.
292. Vats HS. Complications of catheters: tunneled and nontunneled.
Adv Chronic Kidney Dis. 2012;19(3):188-194.
293. Coryell L, Lott JP, Stavropoulos SW, et al. The case for
primary placement of tunneled hemodialysis catheters in acute kidney
injury. J Vasc Interv Radiol. 2009;20(12):1578-1581. quiz 1582.
294. Sequeira A, Sachdeva B, Abreo K. Uncommon complications
of long-term hemodialysis catheters: adhesion, migration, and
perforation by the catheter tip. Semin Dial. 2010;23(1):100-104.
References
S154 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
295. Liu T, Hanna N, Summers D. Retained central venous haemodialysis
access catheters. Nephrol Dial Transplant. 2007;22(3):
960-961. author reply 961.
296. Miller DL, O’Grady NP, Society of Interventional R. Guidelines
for the prevention of intravascular catheter-related infections:
recommendations relevant to interventional radiology for venous
catheter placement and maintenance. J Vasc Interv Radiol.
2012;23(8):997-1007.
297. O’Grady NP, Alexander M, Burns LA, et al. Summary of
recommendations: Guidelines for the Prevention of Intravascular
Catheter-related Infections. Clin Infect Dis. 2011;52(9):1087-1099.
298. Carrillo RG, Garisto JD, Salman L, Merrill D, Asif A. A novel
technique for tethered dialysis catheter removal using the laser
sheath. Semin Dial. 2009;22(6):688-691.
299. Vellanki VS, Watson D, Rajan DK, Bhola CB, Lok CE. The
stuck catheter: a hazardous twist to the meaning of permanent
catheters. J Vasc Access. 2015;16(4):289-293.
300. Timsit JF, Sebille V, Farkas JC, et al. Effect of subcutaneous
tunneling on internal jugular catheter-related sepsis in critically ill
patients: a prospective randomized multicenter study. JAMA.
1996;276(17):1416-1420.
301. Nalesso F, GF, Muraro E, Brendolan A, Ronco C. Fistula
cannulation with a novel fistula cannula: a review of cannulation
devices and procedures. Blood Purif. 2018;45:278-283.
302. Harwood LE, Wilson BM, Oudshoorn A. Improving vascular
access outcomes: attributes of arteriovenous fistula cannulation
success. Clin Kidney J. 2016;9(2):303-309.
303. MacRae JM, Ahmed SB, Atkar R, Hemmelgarn BR.
A randomized trial comparing buttonhole with rope ladder needling
in conventional hemodialysis patients. Clin J Am Soc Nephrol.
2012;7(10):1632-1638.
304. Macrae JM, Ahmed SB, Hemmelgarn BR, Alberta Kidney
Disease N. Arteriovenous fistula survival and needling technique:
long-term results from a randomized buttonhole trial. Am J Kidney
Dis. 2014;63(4):636-642.
305. Chow J, Rayment G, San Miguel S, Gilbert M. A randomised
controlled trial of buttonhole cannulation for the prevention of fistula
access complications. J Renal Care. 2011;37(2):85-93.
306. Struthers J, Allan A, Peel RK, Lambie SH. Buttonhole
needling of ateriovenous fistulae: a randomized controlled trial.
ASAIO J. 2010;56(4):319-322.
307. Vaux E, King J, Lloyd S, et al. Effect of buttonhole cannulation
with a polycarbonate PEG on in-center hemodialysis fistula
outcomes: a randomized controlled trial. Am J Kidney Dis.
2013;62(1):81-88.
308. Toma S, Shinzato T, Fukui H, et al. A timesaving method to
create a fixed puncture route for the buttonhole technique. Nephrol
Dial Transplant. 2003;18(10):2118-2121.
309. Battistella M, Bhola C, Lok CE. Long-term follow-up of the
Hemodialysis Infection Prevention with Polysporin Ointment (HIPPO)
Study: a quality improvement report. Am J Kidney Dis.
2011;57(3):432-441.
310. Doss S, Schiller B, Moran J. Buttonhole cannulation–an
unexpected outcome. Nephrol Nurs J. 2008;35(4):417-419.
311. Grudzinski A, Mendelssohn D, Pierratos A, Nesrallah G.
A systematic review of buttonhole cannulation practices and outcomes.
Semin Dial. 2013;26(4):465-475.
312. Muir CA, Kotwal SS, Hawley CM, et al. Buttonhole
cannulation and clinical outcomes in a home hemodialysis cohort
and systematic review. Clin J Am Soc Nephrol. 2014;9(1):110-
119.
313. Wong B, Muneer M, Wiebe N, et al. Buttonhole versus ropeladder
cannulation of arteriovenous fistulas for hemodialysis: a systematic
review. Am J Kidney Dis. 2014;64(6):918-936.
314. Schuman E, Alexander P, Ronfeld A. Use of bovine carotid
artery for buttonhole technique hemodialysis. J Vasc Access.
2018;19(1):89-91.
315. Robbin ML, Greene T, Allon M, et al. Prediction of arteriovenous
fistula clinical maturation from postoperative ultrasound
measurements: findings from the Hemodialysis Fistula Maturation
Study. J Am Soc Nephrol. 2018;29(11):2735-2744.
316. Rayner HC, Pisoni RL, Gillespie BW, et al. Creation, cannulation
and survival of arteriovenous fistulae: data from the Dialysis
Outcomes and Practice Patterns Study. Kidney Int. 2003;63(1):
323-330.
317. Saran R, Dykstra DM, Pisoni RL, et al. Timing of first cannulation
and vascular access failure in haemodialysis: an analysis of
practice patterns at dialysis facilities in the DOPPS. Nephrol Dial
Transplant. 2004;19(9):2334-2340.
318. Lok CE, Mokrzycki MH. Prevention and management of
catheter-related infection in hemodialysis patients. Kidney Int.
2011;79(6):587-598.
319. Mermel LA, Allon M, Bouza E, et al. Clinical practice
guidelines for the diagnosis and management of intravascular
catheter-related infection: 2009 Update by the Infectious Diseases
Society of America. Clin Infect Dis. 2009;49(1):1-45.
320. Schwab SJ. Assessing the adequacy of vascular access
and its relationship to patient outcome. Am J Kidney Dis.
1994;24(2):316-320.
321. Tordoir J, Canaud B, Haage P, et al. EBPG on vascular
access. Nephrol Dial Transplant. 2007;22(Suppl 2):ii88-ii117.
322. Lee DH, Jung KY, Choi YH. Use of maximal sterile barrier
precautions and/or antimicrobial-coated catheters to reduce the risk
of central venous catheter-related bloodstream infection. Infect
Control Hosp Epidemiol. 2008;29(10):947-950.
323. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central
venous catheter-related infections by using maximal sterile barrier
precautions during insertion. Infect Control Hosp Epidemiol.
1994;15(4 Pt 1):231-238.
324. Mokrzycki MH, Zhang M, Cohen H, Golestaneh L, Laut JM,
Rosenberg SO. Tunnelled haemodialysis catheter bacteraemia: risk
factors for bacteraemia recurrence, infectious complications and
mortality. Nephrol Dial Transplant. 2006;21(4):1024-1031.
325. Beathard GA. Catheter management protocol for catheterrelated
bacteremia prophylaxis. Semin Dial. 2003;16(5):403-405.
326. Rosenblum A, Wang W, Ball LK, Latham C, Maddux FW,
Lacson Jr E. Hemodialysis catheter care strategies: a clusterrandomized
quality improvement initiative. Am J Kidney Dis.
2014;63(2):259-267.
327. McCann M, Fitzpatrick F, Mellotte G, Clarke M. Is 2%
chlorhexidine gluconate in 70% isopropyl alcohol more effective at
preventing central venous catheter-related infections than routinely
used chlorhexidine gluconate solutions: a pilot multicenter randomized
trial (ISRCTN2657745)? Am J Infect Control. 2016;44(8):948-
949.
328. Onder AM, Chandar J, Billings A, et al. Chlorhexidine-based
antiseptic solutions effectively reduce catheter-related bacteremia.
Pediatr Nephrol. 2009;24(9):1741.
329. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S.
Chlorhexidine compared with povidone-iodine solution for vascular
catheter-site care: a meta-analysis. Ann Intern Med. 2002;136(11):
792-801.
330. Winterbottom A, Bekker HL, Conner M, Mooney A.
Choosing dialysis modality: decision making in a chronic illness
context. Health Expect. 2014;17(5):710-723.
331. Ishizuka M, Nagata H, Takagi K, Kubota K. Comparison of 0.
05% chlorhexidine and 10% povidone-iodine as cutaneous disinfectant
for prevention of central venous catheter-related
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S155
bloodstream infection: a comparative study. Eur Surg Res.
2009;43(3):286-290.
332. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW,
Conly J. Hemodialysis infection prevention with polysporin ointment.
J Am Soc Nephrol. 2003;14(1):169-179.
333. Levin A, Mason AJ, Jindal KK, Fong IW, Goldstein MB.
Prevention of hemodialysis subclavian vein catheter infections by
topical povidone-iodine. Kidney Int. 1991;40(5):934-938.
334. Sesso R, Barbosa D, Leme IL, et al. Staphylococcus aureus
prophylaxis in hemodialysis patients using central venous catheter:
effect of mupirocin ointment. J Am Soc Nephrol. 1998;9(6):1085-
1092.
335. Johnson DW, van Eps C, Mudge DW, et al. Randomized,
controlled trial of topical exit-site application of honey (Medihoney)
versus mupirocin for the prevention of catheter-associated infections
in hemodialysis patients. J Am Soc Nephrol. 2005;16(5):1456-
1462.
336. Johnson DW, van Eps C, Mudge DW, et al. Randomized,
controlled trial of topical exit-site application of honey (Medihoney)
versus mupirocin for the prevention of catheter-associated infections
in hemodialysis patients. J Am Soc Nephrol. 2005;16(5):1456-
1462.
337. Maki DG, Stolz SS, Wheeler S, Mermel LA. A prospective,
randomized trial of gauze and two polyurethane dressings for site
care of pulmonary artery catheters: implications for catheter management.
Crit Care Med. 1994;22(11):1729-1737.
338. Hoffmann KK, Weber DJ, Samsa GP, Rutala WA. Transparent
polyurethane film as an intravenous catheter dressing. A
meta-analysis of the infection risks. JAMA. 1992;267(15):2072-
2076.
339. Le Corre I, Delorme M, Cournoyer S. A prospective, randomized
trial comparing a transparent dressing and a dry gauze on
the exit site of long term central venous catheters of hemodialysis
patients. J Vasc Access. 2003;4(2):56-61.
340. de Barros LAV, Bettencourt A, Diccini S, Fram D,
Belasco A, et al. Evaluation of two types of dressings used on
central venous catheters for hemodialysis. Acta Paulista de Enfermagem.
2009;22(Especial - Nefrologia):481-486.
341. Hadaway L. Technology of flushing vascular access devices.
J Infusion Nurs. 2006;29(3):137-145.
342. Dutka P, Brickel H. A practical review of the kidney dialysis
outcomes quality initiative (KDOQI) guidelines for hemodialysis
catheters and their potential impact on patient care. Nephrol Nurs J.
2010;37(5):531-535. quiz 536.
343. Audit Tool: Catheter connection and disconnection observations.
https://www.cdc.gov/dialysis/PDFs/collaborative/CatheterConnection-Disconnection-Observations.pdf.
2019.
344. Manns B, Tonelli M, Yilmaz S, et al. Establishment and
maintenance of vascular access in incident hemodialysis patients: a
prospective cost analysis. J Am Soc Nephrol. 2005;16(1):201-209.
345. Viecelli AK, Tong A, O’Lone E, et al. Report of the Standardized
Outcomes in Nephrology-Hemodialysis (SONG-HD)
Consensus Workshop on Establishing a Core Outcome Measure for
Hemodialysis Vascular Access. Am J Kidney Dis. 2018;71(5):690-
700.
346. Tonelli M, James M, Wiebe N, Jindal K, Hemmelgarn B,
Alberta Kidney Disease N. Ultrasound monitoring to detect access
stenosis in hemodialysis patients: a systematic review. Am J Kidney
Dis. 2008;51(4):630-640.
347. Polkinghorne KR, Lau KK, Saunder A, Atkins RC, Kerr PG.
Does monthly native arteriovenous fistula blood-flow surveillance
detect significant stenosis–a randomized controlled trial. Nephrol
Dial Transplant. 2006;21(9):2498-2506.
348. Tessitore N, Lipari G, Poli A, et al. Can blood flow surveillance
and pre-emptive repair of subclinical stenosis prolong the
useful life of arteriovenous fistulae? A randomized controlled study.
Nephrol Dial Transplant. 2004;19(9):2325-2333.
349. Tessitore N, Bedogna V, Poli A, et al. Should current criteria
for detecting and repairing arteriovenous fistula stenosis be reconsidered?
Interim analysis of a randomized controlled trial. Nephrol
Dial Transplant. 2014;29(1):179-187.
350. Sands JJ. Vascular access monitoring improves outcomes.
Blood Purif. 2005;23(1):45-49.
351. Moist LM, Churchill DN, House AA, et al. Regular monitoring
of access flow compared with monitoring of venous pressure fails to
improve graft survival. J Am Soc Nephrol. 2003;14(10):2645-2653.
352. Step 8: Taking Care of My Lifeline for a Lifetime. In. Lifeline
for a Lifetime: ESRD Coordinating Center.
353. Paulson WD, Ram SJ, Work J. Use of vascular access
blood flow to evaluate vascular access. Am J Kidney Dis.
2001;38(4):916.
354. Coentrao L, Faria B, Pestana M. Physical examination of
dysfunctional arteriovenous fistulae by non-interventionalists: a skill
worth teaching. Nephrol Dial Transplant. 2012;27(5):1993-1996.
355. Leon C, Asif A. Physical examination of arteriovenous
fistulae by a renal fellow: does it compare favorably to an experienced
interventionalist? Semin Dial. 2008;21(6):557-560.
356. Leon C, Orozco-Vargas LC, Krishnamurthy G, et al. Accuracy
of physical examination in the detection of arteriovenous graft
stenosis. Semin Dial. 2008;21(1):85-88.
357. Frinak S, Zasuwa G, Dunfee T, Besarab A, Yee J. Dynamic
venous access pressure ratio test for hemodialysis access monitoring.
Am J Kidney Dis. 2002;40(4):760-768.
358. Tonelli M, Hirsch DJ, Chan CT, et al. Factors associated with
access blood flow in native vessel arteriovenous fistulae. Nephrol
Dial Transplant. 2004;19(10):2559-2563.
359. Polkinghorne KR, Atkins RC, Kerr PG. Determinants of
native arteriovenous fistula blood flow. Nephrology (Carlton).
2004;9(4):205-211.
360. Robbin ML, Oser RF, Lee JY, Heudebert GR,
Mennemeyer ST, Allon M. Randomized comparison of ultrasound
surveillance and clinical monitoring on arteriovenous graft outcomes.
Kidney Int. 2006;69(4):730-735.
361. Bacchini G, Cappello A, La Milia V, Andrulli S, Locatelli F.
Color doppler ultrasonography imaging to guide transluminal angioplasty
of venous stenosis. Kidney Int. 2000;58(4):1810-1813.
362. Paulson WD, Moist L, Lok CE. Vascular access surveillance:
an ongoing controversy. Kidney Int. 2012;81(2):132-142.
363. Paulson WD, Ram SJ, Birk CG, Zapczynski M, Martin SR,
Work J. Accuracy of decrease in blood flow in predicting hemodialysis
graft thrombosis. Am J Kidney Dis. 2000;35(6):1089-1095.
364. Polkinghorne KR, Atkins RC, Kerr PG. Native arteriovenous
fistula blood flow and resistance during hemodialysis. Am J Kidney
Dis. 2003;41(1):132-139.
365. Tessitore N, Bedogna V, Melilli E, et al. In search of an
optimal bedside screening program for arteriovenous fistula stenosis.
Clin J Am Soc Nephrol. 2011;6(4):819-826.
366. Roy-Chaudhury P, Sukhatme VP, Cheung AK. Hemodialysis
vascular access dysfunction: a cellular and molecular viewpoint.
J Am Soc Nephrol. 2006;17(4):1112-1127.
367. Allon M, Robbin ML. Hemodialysis vascular access monitoring:
current concepts. Hemodial Int. 2009;13(2):153-162.
368. Schuman E, Ronfeld A, Barclay C, Heinl P. Comparison of
clinical assessment with ultrasound flow for hemodialysis access
surveillance. Arch Surg. 2007;142(12):1129-1133.
369. Krivitski NM, MacGibbon D, Gleed RD, Dobson A. Accuracy
of dilution techniques for access flow measurement during hemodialysis.
Am J Kidney Dis. 1998;31(3):502-508.
370. Chan KE, Pflederer TA, Steele DJ, et al. Access survival
amongst hemodialysis patients referred for preventive angiography
References
S156 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
and percutaneous transluminal angioplasty. Clin J Am Soc Nephrol.
2011;6(11):2669-2680.
371. Schwarz C, Mitterbauer C, Boczula M, et al. Flow monitoring:
performance characteristics of ultrasound dilution versus
color Doppler ultrasound compared with fistulography. Am J Kidney
Dis. 2003;42(3):539-545.
372. Tessitore N, Bedogna V, Gammaro L, et al. Diagnostic accuracy
of ultrasound dilution access blood flow measurement in
detecting stenosis and predicting thrombosis in native forearm
arteriovenous fistulae for hemodialysis. Am J Kidney Dis.
2003;42(2):331-341.
373. Dember LM, Holmberg EF, Kaufman JS. Randomized
controlled trial of prophylactic repair of hemodialysis arteriovenous
graft stenosis. Kidney Int. 2004;66(1):390-398.
374. Lumsden AB, MacDonald MJ, Kikeri D, Cotsonis GA,
Harker LA, Martin LG. Prophylactic balloon angioplasty fails to prolong
the patency of expanded polytetrafluoroethylene arteriovenous
grafts: results of a prospective randomized study. J Vasc Surg.
1997;26(3):382-390; discussion 390-382.
375. Ram SJ, Work J, Caldito GC, Eason JM, Pervez A,
Paulson WD. A randomized controlled trial of blood flow and stenosis
surveillance of hemodialysis grafts. Kidney Int. 2003;64(1):
272-280.
376. Malik J, Slavikova M, Svobodova J, Tuka V. Regular ultrasonographic
screening significantly prolongs patency of PTFE grafts.
Kidney Int. 2005;67(4):1554-1558.
377. Tessitore N, Mansueto G, Bedogna V, et al. A prospective
controlled trial on effect of percutaneous transluminal angioplasty on
functioning arteriovenous fistulae survival. J Am Soc Nephrol.
2003;14(6):1623-1627.
378. Campos RP, Chula DC, Perreto S, Riella MC, do
Nascimento MM. Accuracy of physical examination and intra-access
pressure in the detection of stenosis in hemodialysis arteriovenous
fistula. Semin Dial. 2008;21(3):269-273.
379. Aragoncillo I, Amezquita Y, Caldes S, et al. The impact of
access blood flow surveillance on reduction of thrombosis in native
arteriovenous fistula: a randomized clinical trial. J Vasc Access.
2016;17(1):13-19.
380. Beathard GA. Physical examination of the dialysis vascular
access. Semin Dial. 1998;11(4):231-236.
381. Beathard GA. An algorithm for the physical examination of
early fistula failure. Semin Dial. 2005;18(4):331-335.
382. Lin CC, Chang CF, Lai MY, Chen TW, Lee PC, Yang WC.
Far-infrared therapy: a novel treatment to improve access blood flow
and unassisted patency of arteriovenous fistula in hemodialysis patients.
J Am Soc Nephrol. 2007;18(3):985-992.
383. Lin CC, Yang WC, Chen MC, Liu WS, Yang CY, Lee PC.
Effect of far infrared therapy on arteriovenous fistula maturation: an
open-label randomized controlled trial. Am J Kidney Dis.
2013;62(2):304-311.
384. Lin CC, Chung MY, Yang WC, Lin SJ, Lee PC. Length
polymorphisms of heme oxygenase-1 determine the effect of farinfrared
therapy on the function of arteriovenous fistula in hemodialysis
patients: a novel physicogenomic study. Nephrol Dial Transplant.
2013;28(5):1284-1293.
385. Lai CC, Fang HC, Mar GY, Liou JC, Tseng CJ, Liu CP. Postangioplasty
far infrared radiation therapy improves 1-year
angioplasty-free hemodialysis access patency of recurrent obstructive
lesions. European J Vasc Endovasc Surg. 2013;46(6):726-732.
386. Irish AB, Viecelli AK, Hawley CM, et al. Effect of fish oil
supplementation and aspirin use on arteriovenous fistula failure in
patients requiring hemodialysis: a randomized clinical trial. JAMA
Intern Med. 2017;177(2):184-193.
387. Herrington W, Emberson J, Staplin N, et al. The effect of
lowering LDL cholesterol on vascular access patency: post hoc
analysis of the Study of Heart and Renal Protection. Clin J Am Soc
Nephrol. 2014;9(5):914-919.
388. Lok CE, Moist L, Hemmelgarn BR, et al. Effect of fish oil
supplementation on graft patency and cardiovascular events among
patients with new synthetic arteriovenous hemodialysis grafts: a
randomized controlled trial. JAMA. 2012;307(17):1809-1816.
389. Bowden RG, Wilson RL, Gentile M, Ounpraseuth S,
Moore P, Leutholtz BC. Effects of omega-3 fatty acid supplementation
on vascular access thrombosis in polytetrafluorethylene grafts.
J Ren Nutr. 2007;17(2):126-131.
390. Dixon BS, Beck GJ, Dember LM, et al. Use of aspirin associates
with longer primary patency of hemodialysis grafts. J Am
Soc Nephrol. 2011;22(4):773-781.
391. Kaufman JS, O’Connor TZ, Zhang JH, et al. Randomized
controlled trial of clopidogrel plus aspirin to prevent hemodialysis
access graft thrombosis. J Am Soc Nephrol. 2003;14(9):2313-
2321.
392. Crowther MA, Clase CM, Margetts PJ, et al. Low-intensity
warfarin is ineffective for the prevention of PTFE graft failure in patients
on hemodialysis: a randomized controlled trial. J Am Soc
Nephrol. 2002;13(9):2331-2337.
393. Riella MC, Roy-Chaudhury P. Vascular access in haemodialysis:
strengthening the Achilles’ heel. Nat Rev Nephrol.
2013;9(6):348-357.
394. Roy-Chaudhury P, Wang Y, Krishnamoorthy M, et al. Cellular
phenotypes in human stenotic lesions from haemodialysis vascular
access. Nephrol Dial Transplant. 2009;24(9):2786-2791.
395. Nassar GM, Rhee E, Khan AJ, Nguyen B, Achkar K,
Beathard G. Percutaneous thrombectomy of AVF: immediate success
and long-term patency rates. Semin Dial. 2015;28(2):E15-
E22.
396. Collins AJ, Foley RN, Herzog C, et al. US Renal Data
System 2012 Annual Data Report. Am J Kidney Dis. 2013;61(1
Suppl 1). A7, e1-476.
397. Collins AJ, Foley RN, Herzog C, et al. United States Renal
Data System 2008 Annual Data Report. Am J Kidney Dis.
2009;53(1 Suppl):S1-374.
398. Kuo TH, Tseng CT, Lin WH, et al. Association Between
Vascular Access Dysfunction and Subsequent Major Adverse Cardiovascular
Events in Patients on Hemodialysis: A Population-Based
Nested Case-Control Study. Medicine (Baltimore). 2015;94(26):
e1032.
399. Duque JC, Tabbara M, Martinez L, Cardona J, VazquezPadron
RI, Salman LH. Dialysis Arteriovenous Fistula Failure and
Angioplasty: Intimal Hyperplasia and Other Causes of Access Failure.
Am J Kidney Dis. 2017;69(1):147-151.
400. Quencer KB, Kidd J, Kinney T. Preprocedure Evaluation of a
Dysfunctional Dialysis Access. Tech Vasc Interv Radiol. 2017;20(1):
20-30.
401. Nassar GM, Beathard G, Rhee E, Khan AJ, Nguyen B.
Management of transposed arteriovenous fistula swing point stenosis
at the basilic vein angle of transposition by stent grafts. J Vasc
Access. 2017;18(6):482-487.
402. Kakkos SK, Kouri AK, Tsolakis IA, Haddad GK,
Lampropoulos GC, Karnabatidis D. Surgical and endovascular
revision of brachio-basilic vein fistula. J Vasc Access. 2016;17(Suppl
1):S6-S11.
403. Ravani P, Quinn RR, Oliver MJ, et al. Pre-emptive correction
for haemodialysis arteriovenous access stenosis. Cochrane Database
Syst Rev 2016;(1):CD010709.
404. Leontiev O, Shlansky-Goldberg RD, Stavropoulos SW, et al.
Should all inflow stenoses be treated in failing autogenous hemodialysis
fistulae? J Vasc Interv Radiol. 2014;25(4):542-547.
405. Li B, Li Q, Chen C, Guan Y, Liu S. Diagnostic accuracy of
computer tomography angiography and magnetic resonance
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S157
angiography in the stenosis detection of autologuous hemodialysis
access: a meta-analysis. PLoS One. 2013;8(10):e78409.
406. Kariya S, Tanigawa N, Kojima H, et al. Efficacy of carbon
dioxide for diagnosis and intervention in patients with failing hemodialysis
access. Acta Radiol. 2010;51(9):994-1001.
407. Ross JR, Franga DL, Gallichio M, Patel AJ, Ouriel K. Role of
intravascular ultrasound imaging during endovascular interventions
of failing hemodialysis access grafts. J Vasc Surg. 2017;65(5):1383-
1389.
408. Bode AS, Planken RN, Merkx MA, et al. Feasibility of noncontrast-enhanced
magnetic resonance angiography for imaging
upper extremity vasculature prior to vascular access creation. Eur J
Vasc Endovasc Surg. 2012;43(1):88-94.
409. Yevzlin AS, Chan MR, Becker YT, Roy-Chaudhury P, Lee T,
Becker BN. "Venopathy" at work: recasting neointimal hyperplasia in
a new light. Transl Res. 2010;156(4):216-225.
410. Lee T, Roy-Chaudhury P. Advances and new frontiers in the
pathophysiology of venous neointimal hyperplasia and dialysis access
stenosis. Adv Chronic Kidney Dis. 2009;16(5):329-338.
411. Woods JD, Turenne MN, Strawderman RL, et al. Vascular
access survival among incident hemodialysis patients in the United
States. Am J Kidney Dis. 1997;30(1):50-57.
412. Chang CJ, Ko PJ, Hsu LA, et al. Highly increased cell proliferation
activity in the restenotic hemodialysis vascular access after
percutaneous transluminal angioplasty: implication in prevention of
restenosis. Am J Kidney Dis. 2004;43(1):74-84.
413. Katsanos K, Karnabatidis D, Kitrou P, Spiliopoulos S,
Christeas N, Siablis D. Paclitaxel-coated balloon angioplasty vs. plain
balloon dilation for the treatment of failing dialysis access: 6-month
interim results from a prospective randomized controlled trial.
J Endovasc Ther. 2012;19(2):263-272.
414. Kitrou PM, Spiliopoulos S, Katsanos K, Papachristou E,
Siablis D, Karnabatidis D. Paclitaxel-coated versus plain balloon
angioplasty for dysfunctional arteriovenous fistulae: one-year results
of a prospective randomized controlled trial. J Vasc Interv Radiol.
2015;26(3):348-354.
415. Lai CC, Fang HC, Tseng CJ, Liu CP, Mar GY. Percutaneous
angioplasty using a paclitaxel-coated balloon improves target lesion
restenosis on inflow lesions of autogenous radiocephalic fistulas: a
pilot study. J Vasc Interv Radiol. 2014;25(4):535-541.
416. Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M,
Karnabatidis D. Risk of death following application of paclitaxel
coated balloons and stents in the femoropopliteal artery of the leg: a
systematic review and analysis of randomized controlled trials. J Am
Heart Assoc. 2018;7(24):e011245.
417. Aftab SA, Tay KH, Irani FG, et al. Randomized clinical trial of
cutting balloon angioplasty versus high-pressure balloon angioplasty
in hemodialysis arteriovenous fistula stenoses resistant to conventional
balloon angioplasty. J Vasc Interv Radiol. 2014;25(2):190-
198.
418. Rasuli P, Chennur VS, Connolly MJ, et al. Randomized trial
comparing the primary patency following cutting versus highpressure
balloon angioplasty for treatment of de novo venous stenoses
in hemodialysis arteriovenous fistulae. J Vasc Interv Radiol.
2015;26(12):1840-1846.e1841.
419. Forauer AR, Hoffer EK, Homa K. Dialysis access venous
stenoses: treatment with balloon angioplasty–1- versus 3-minute
inflation times. Radiology. 2008;249(1):375-381.
420. Elramah M, Boujelbane L, Yevzlin AS, Wakeen M, Astor BC,
Chan MR. Dialysis access venous stenosis: treatment with balloon
angioplasty 30-second vs. 1-minute inflation times. Hemodial Int.
2015;19(1):108-114.
421. Haskal ZJ, Trerotola S, Dolmatch B, et al. Stent graft versus
balloon angioplasty for failing dialysis-access grafts. N Engl J Med.
2010;362(6):494-503.
422. Vesely T, DaVanzo W, Behrend T, Dwyer A, Aruny J. Balloon
angioplasty versus Viabahn stent graft for treatment of failing or
thrombosed prosthetic hemodialysis grafts. J Vasc Surg.
2016;64(5):1400-1410.e1401.
423. Vesely T, DaVanzo W, Behrend T, Dwyer A, Aruny J. Balloon
angioplasty versus Viabahn stent graft for treatment of failing or
thrombosed prosthetic hemodialysis grafts. J Vasc Surg. 2016;11.
424. Haskal ZJ, Saad TF, Hoggard JG, et al. Prospective, randomized,
concurrently-controlled study of a stent graft versus
balloon angioplasty for treatment of arteriovenous access graft
stenosis: 2-year results of the RENOVA study. J Vasc Interv Radiol.
2016;27(8):1105-1114.e1103.
425. Shemesh D, Goldin I, Zaghal I, Berlowitz D, Raveh D,
Olsha O. Angioplasty with stent graft versus bare stent for recurrent
cephalic arch stenosis in autogenous arteriovenous access for hemodialysis:
a prospective randomized clinical trial. J Vasc Surg.
2008;48(6):1524-1531. 1531.e1521-1522.
426. Rajan DK, Falk A. A randomized prospective study
comparing outcomes of angioplasty versus VIABAHN stent-graft
placement for cephalic arch stenosis in dysfunctional hemodialysis
accesses. J Vasc Interv Radiol. 2015;26(9):1355-1361.
427. Falk A, Maya ID, Yevzlin AS. A prospective, randomized study
of an expanded polytetrafluoroethylene stent graft versus balloon
angioplasty for in-stent restenosis in arteriovenous grafts and
fistulae: two-year results of the RESCUE study. J Vasc Interv Radiol.
2016;27(10):1465-1476.
428. Beathard GA, Welch BR, Maidment HJ. Mechanical
thrombolysis for the treatment of thrombosed hemodialysis access
grafts. Radiology. 1996;200(3):711-716.
429. Schon D, Mishler R. Pharmacomechanical thrombolysis of
natural vein fistulas: reduced dose of TPA and long-term follow-up.
Semin Dial. 2003;16(3):272-275.
430. Chan N, Wee I, Soong TK, Syn N, Choong A. A systematic
review and meta-analysis of surgical versus endovascular thrombectomy
of thrombosed arteriovenous grafts in hemodialysis patients.
J Vasc Surg. 2019;69(6):1976-1988 e1977.
431. Tordoir JH, Bode AS, Peppelenbosch N, Van Der Sande FM,
de Haan MW. Surgical or endovascular repair of thrombosed dialysis
vascular access: is there any evidence? J Vasc Surg. 2009;50(4):
953-956.
432. Forsythe RO, Chemla ES. Surgical options in the problematic
arteriovenous haemodialysis access. Cardiovasc Intervent
Radiol. 2015;38(6):1405-1415.
433. Belli S, Yabanoglu H, Aydogan C, Parlakgumus A, Yildirim S,
Haberal M. Surgical interventions for late complications of arteriovenous
fistulas. Int Surg. 2014;99(4):467-474.
434. Romann A, Beaulieu MC, Rheaume P, Clement J, Sidhu R,
Kiaii M. Risk factors associated with arteriovenous fistula failure after
first radiologic intervention. J Vasc Access. 2016;17(2):167-174.
435. Sigala F, Sassen R, Kontis E, Kiefhaber LD, Forster R,
Mickley V. Surgical treatment of cephalic arch stenosis by central
transposition of the cephalic vein. J Vasc Access. 2014;15(4):272-
277.
436. Davies MG, Hicks TD, Haidar GM, El-Sayed HF. Outcomes
of intervention for cephalic arch stenosis in brachiocephalic arteriovenous
fistulas. J Vasc Surg. 2017;66(5):1504-1510.
437. Vasanthamohan L, Gopee-Ramanan P, Athreya S. The
management of cephalic arch stenosis in arteriovenous fistulas for
hemodialysis: a systematic review. Cardiovasc Intervent Radiol.
2015;38(5):1179-1185.
438. Quencer KB, Friedman T. Declotting the thrombosed access.
Tech Vasc Interv Radiol. 2017;20(1):38-47.
439. Salmela B, Hartman J, Peltonen S, Alback A, Lassila R.
Thrombophilia and arteriovenous fistula survival in ESRD. Clin J Am
Soc Nephrol. 2013;8(6):962-968.
References
S158 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
440. Green LD, Lee DS, Kucey DS. A metaanalysis comparing
surgical thrombectomy, mechanical thrombectomy, and pharmacomechanical
thrombolysis for thrombosed dialysis grafts. J Vasc Surg.
2002;36(5):939-945.
441. Kuhan G, Antoniou GA, Nikam M, et al. A meta-analysis of
randomized trials comparing surgery versus endovascular therapy
for thrombosed arteriovenous fistulas and grafts in hemodialysis.
Cardiovasc Intervent Radiol. 2013;36(3):699-705.
442. Troisi N, Chisci E, Frosini P, et al. Hybrid simultaneous
treatment of thrombosed prosthetic grafts for hemodialysis. J Vasc
Access. 2014;15(5):396-400.
443. Bachleda P, Janeckova J, Xinopulos P, Smakal O. New
hybrid procedures in treating occluded arteriovenous hemodialysis
grafts. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub.
2016;160(1):149-152.
444. Cull DL, Washer JD, Carsten CG, Keahey G, Johnson B.
Description and outcomes of a simple surgical technique to treat
thrombosed autogenous accesses. J Vasc Surg. 2012;56(3):861-
865.
445. Rabin I, Shani M, Mursi J, et al. Effect of timing of thrombectomy
on survival of thrombosed arteriovenous hemodialysis
grafts. Vasc Endovascular Surg. 2013;47(5):342-345.
446. Sadaghianloo N, Jean-Baptiste E, Gaid H, et al. Early surgical
thrombectomy improves salvage of thrombosed vascular accesses.
J Vasc Surg. 2014;59(5):1377-1384. e1371-1372.
447. Malka KT, Flahive J, Csizinscky A, et al. Results of repeated
percutaneous interventions on failing arteriovenous fistulas and
grafts and factors affecting outcomes. J Vasc Surg. 2016;63(3):
772-777.
448. Nikam MD, Ritchie J, Jayanti A, et al. Acute arteriovenous
access failure: long-term outcomes of endovascular salvage and
assessment of co-variates affecting patency. Nephron.
2015;129(4):241-246.
449. Simoni E, Blitz L, Lookstein R. Outcomes of AngioJet(R)
thrombectomy in hemodialysis vascular access grafts and fistulas:
PEARL I Registry. J Vasc Access. 2013;14(1):72-76.
450. Rosenberg JE, Yevzlin AS, Chan MR, Valliant AM, Astor BC.
Prediction of arteriovenous fistula dysfunction: can it be taught?
Semin Dial. 2015;28(5):544-547.
451. Gallieni M, Martini A, Mezzina N. Dialysis access: an
increasingly important clinical issue. Int J Artif Organs. 2009;32(12):
851-856.
452. Patel PR, Kallen AJ, Arduino MJ. Epidemiology, surveillance,
and prevention of bloodstream infections in hemodialysis patients.
Am J Kidney Dis. 2010;56(3):566-577.
453. Anderson JE, Chang AS, Anstadt MP. Polytetrafluoroethylene
hemoaccess site infections. Asaio j. 2000;46(6):S18-S21.
454. Bachleda P, Kalinova L, Utikal P, Kolar M, Hricova K,
Stosova T. Infected prosthetic dialysis arteriovenous grafts: a single
dialysis center study. Surg Infect (Larchmt ). 2012;13(6):366-370.
455. Solid C, Foley R. Vascular access use and access infections
from dialysis claims data. Paper presented at: Kidney Week 2012;
October 30-November 4, 2012; San Diego, CA.
456. Christensen LD, Skadborg MB, Mortensen AH, et al.
Bacteriology of the buttonhole cannulation tract in hemodialysis
patients: a prospective cohort study. Am J Kidney Dis. 2018;72(2):
234-242.
457. Al-Jaishi AA, Liu AR, Lok CE, Zhang JC, Moist LM. Complications
of the arteriovenous fistula: a systematic review. J Am Soc
Nephrol. 2017;28(6):1839-1850.
458. Zhang J, Burr RA, Sheth HS, Piraino B. Organism-specific
bacteremia by hemodialysis access. Clin Nephrol. 2016;86(9):141-
146.
459. Tabbara MR, O’Hara PJ, Hertzer NR, Krajewski LP,
Beven EG. Surgical management of infected PTFE hemodialysis
grafts: analysis of a 15-year experience. Ann Vasc Surg. 1995;9(4):
378-384.
460. Akoh JA, Patel N. Infection of hemodialysis arteriovenous
grafts. J Vasc Access. 2010;11(2):155-158.
461. Lafrance JP, Rahme E, Lelorier J, Iqbal S. Vascular accessrelated
infections: definitions, incidence rates, and risk factors. Am J
Kidney Dis. 2008;52(5):982-993.
462. Harish A, Allon M. Arteriovenous graft infection: a comparison
of thigh and upper extremity grafts. Clin J Am Soc Nephrol.
2011;6(7):1739-1743.
463. Minga TE, Flanagan KH, Allon M. Clinical consequences of
infected arteriovenous grafts in hemodialysis patients. Am J Kidney
Dis. 2001;38(5):975-978.
464. Lew SQ, Kaveh K. Dialysis access related infections. Asaio
j. 2000;46(6):S6-12.
465. Schneider JR, White GW, Dejesus EF. Pasteurella
multocida-infected expanded polytetrafluoroethylene hemodialysis
access graft. Ann Vasc Surg. 2012;26(8); 1128.e1115-1127.
466. Onorato IM, Axelrod JL, Lorch JA, Brensilver JM,
Bokkenheuser V. Fungal infections of dialysis fistulae. Ann Intern
Med. 1979;91(1):50-52.
467. Legout L, D’Elia PV, Sarraz-Bournet B, et al. Diagnosis and
management of prosthetic vascular graft infections. Med Mal Infect.
2012;42(3):102-109.
468. Ayus JC, Sheikh-Hamad D. Silent infection in clotted
hemodialysis access grafts. J Am Soc Nephrol. 1998;9(7):1314-
1317.
469. Cull JD, Cull DL, Taylor SM, et al. Prosthetic thigh arteriovenous
access: outcome with SVS/AAVS reporting standards.
J Vasc Surg. 2004;39(2):381-386.
470. Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS,
Nikolopoulos ES, Giannoukas AD. Lower-extremity arteriovenous
access for haemodialysis: a systematic review. Eur J Vasc Endovasc
Surg. 2009;38(3):365-372.
471. Balaz P, Bjorck M. True aneurysm in autologous hemodialysis:
definitions, classification and indications for treatment. J Vasc
Access. 2015;16(6):446-453.
472. Inston N, Mistry H, Gilbert J, et al. Aneurysms in vascular
access: state of the art and future developments. J Vasc Access.
2017;18(6):464-472.
473. Rajput A, Rajan DK, Simons ME, et al. Venous aneurysms in
autogenous hemodialysis fistulas: is there an association with
venous outflow stenosis. J Vasc Access. 2013;14(2):126-130.
474. Valenti D, Mistry H, Stephenson M. A novel classification
system for autogenous arteriovenous fistula aneurysms in renal access
patients. Vasc Endovascular Surg. 2014;48(7-8):491-496.
475. Kordzadeh A, D’Espiney Barbara RM, Ahmad AS, Hanif MA,
Panayiotopoulos YP. Donor artery aneurysm formation following the
ligation of haemodialysis arteriovenous fistula: a systematic review
and case reports. J Vasc Access. 2015;16(1):5-12.
476. Jose MD, Marshall MR, Read G, et al. Fatal Dialysis Vascular
Access Hemorrhage. Am J Kidney Dis. 2017;70(4):570-575.
477. Lazarides MK, Georgiadis GS, Argyriou C. Aneurysm formation
and infection in AV prosthesis. J Vasc Access.
2014;15(Suppl 7):S120-124.
478. Hedin U, Engstrom J, Roy J. Endovascular treatment of true
and false aneurysms in hemodialysis access. J Cardiovasc Surg
(Torino). 2015;56(4):599-605.
479. Wang S, Wang MS. Successful use of partial aneurysmectomy
and repair approach for managing complications of
arteriovenous fistulas and grafts. J Vasc Surg. 2017;66(2):545-553.
480. Woo K, Cook PR, Garg J, Hye RJ, Canty TG. Midterm results
of a novel technique to salvage autogenous dialysis access in
aneurysmal arteriovenous fistulas. J Vasc Surg. 2010;51(4):921-
925. 925.
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S159
481. Vo T, Tumbaga G, Aka P, Behseresht J, Hsu J, Tayarrah M.
Staple aneurysmorrhaphy to salvage autogenous arteriovenous fistulas
with aneurysm-related complications. J Vasc Surg. 2015;61(2):
457-462.
482. Rokosny S, Balaz P, Wohlfahrt P, Palous D, Janousek L.
Reinforced aneurysmorrhaphy for true aneurysmal haemodialysis
vascular access. Eur J Vasc Endovasc Surg. 2014;47(4):444-450.
483. Fotiadis N, Shawyer A, Namagondlu G, Iyer A, Matson M,
Yaqoob MM. Endovascular repair of symptomatic hemodialysis access
graft pseudoaneurysms. J Vasc Access. 2014;15(1):5-11.
484. Zink JN, Netzley R, Erzurum V, Wright D. Complications of
endovascular grafts in the treatment of pseudoaneurysms and stenoses
in arteriovenous access. J Vasc Surg. 2013;57(1):144-148.
485. Wilson NA, Shenoy S. Managing ‘buttonhole’ complications.
J Vasc Access. 2014;15(7_suppl):91-95.
486. Jose MD, Marshall MR, Read G, et al. Fatal Dialysis Vascular
Access Hemorrhage. Am J Kidney Dis. 2017;70(4):570-575.
487. Sidawy AN, Gray R, Besarab A, et al. Recommended
standards for reports dealing with arteriovenous hemodialysis accesses.
J Vasc Surg. 2002;35(3):603-610.
488. Chemla E, Raynaud A, Carreres T, et al. Preoperative
assessment of the efficacy of distal radial artery ligation in treatment
of steal syndrome complicating access for hemodialysis. Ann Vasc
Surg. 1999;13(6):618-621.
489. Miller GA, Khariton K, Kardos SV, Koh E, Goel N, Khariton A.
Flow interruption of the distal radial artery: treatment for finger
ischemia in a matured radiocephalic AVF. J Vasc Access. 2008;9(1):
58-63.
490. Ferrante L, Faggioli G, Pini R, D’Amico R, Mauro R, Stella A.
Plication for the treatment of a radio-cephalic fistula with ulnar artery
steal. Int J Artif Organs. 2016;39(2):90-93.
491. Cordova E, Pettorini L, Scrivano J, et al. Preoperative duplex
examination in patients with dialysis access-related hand ischemia:
indication for distal radial artery ligation. J Vasc Access. 2015;16(3):
255-257.
492. Hye RJ, Wolf YG. Ischemic monomelic neuropathy: an
under-recognized complication of hemodialysis access. Ann Vasc
Surg. 1994;8(6):578-582.
493. Wilbourn AJ, Furlan AJ, Hulley W, Ruschhaupt W. Ischemic
monomelic neuropathy. Neurology. 1983;33(4):447-451.
494. Thermann F, Kornhuber M. Ischemic monomelic neuropathy:
a rare but important complication after hemodialysis access placement–a
review. J Vasc Access. 2011;12(2):113-119.
495. Coscione AI, Gale-Grant O, Maytham GD. Early access
ligation resolves presumed ischaemic monomelic neuropathy in a
patient with recurrence of central venous occlusion. J Vasc Access.
2015;16(4):344-346.
496. Sasaki Y, Shiozaki K, Ozaki K, et al. [Seroma formation
associated with expanded polytetrafluoroethylene graft used for
dialysis access: a case report]. Hinyokika Kiyo. 2014;60(10):489-
491.
497. Dauria DM, Dyk P, Garvin P. Incidence and management of
seroma after arteriovenous graft placement. J Am Coll Surg.
2006;203(4):506-511.
498. Sequeira A, Tan TW. Complications of a High-flow Access
and Its Management. Semin Dial. 2015;28(5):533-543.
499. Chuang MK, Chang CH, Chan CY. The effect of haemodialysis
access types on cardiac performance and morbidities in
patients with symptomatic heart disease. PLoS One. 2016;11(2):
e0148278.
500. Basile C, Lomonte C, Vernaglione L, Casucci F, Antonelli M,
Losurdo N. The relationship between the flow of arteriovenous fistula
and cardiac output in haemodialysis patients. Nephrol Dial Transplant.
2007;1:282-287.
501. Kanno T, Kamijo Y, Hashimoto K, Kanno Y. Outcomes of
blood flow suppression methods of treating high flow access in
hemodialysis patients with arteriovenous fistula. J Vasc Access.
2015;16(Suppl 10):S28-33.
502. Gkotsis G, Jennings WC, Malik J, Mallios A, Taubman K.
Treatment of high flow arteriovenous fistulas after successful renal
transplant using a simple precision banding technique. Ann Vasc
Surg. 2016;31:85-90.
503. Shintaku S, Kawanishi H, Moriishi M, Banshodani M, Ago R,
Tsuchiya S. Modified MILLER banding procedure for managing highflow
access and dialysis-associated steal syndrome. J Vasc Access
2015;(3):227-232.
504. Vaes RH, van Loon M, Vaes SM, Cuypers P, Tordoir JH,
Scheltinga MR. One-year efficacy of the RUDI technique for flow
reduction in high-flow autologous brachial artery-based hemodialysis
vascular access. J Vasc Access. 2015;16(Suppl 9):S96-S101.
505. Aitken E, Kerr D, Geddes C, Berry C, Kingsmore D. Cardiovascular
changes occurring with occlusion of a mature arteriovenous
fistula. J Vasc Access. 2015;16(6):459-466.
506. Hemmelgarn BR, Moist LM, Lok CE, et al. Prevention of
dialysis catheter malfunction with recombinant tissue plasminogen
activator. N Engl J Med. 2011;364(4):303-312.
507. Han X, Yang X, Huang B, Yuan L, Cao Y. Low-dose versus
high-dose heparin locks for hemodialysis catheters: a systematic
review and meta-analysis. Clin Nephrol. 2016;86(7):1-8.
508. Wang Y, Ivany JN, Perkovic V, Gallagher MP, Woodward M,
Jardine MJ. Anticoagulants and antiplatelet agents for preventing
central venous haemodialysis catheter malfunction in patients with
end-stage kidney disease. Cochrane Database of Systematic Reviews
2016;(4).
509. Carson RC, Kiaii M, MacRae JM. Urea clearance in
dysfunctional catheters is improved by reversing the line position
despite increased access recirculation. Am J Kidney Dis.
2005;45(5):883-890.
510. Moist LM, Hemmelgarn BR, Lok CE. Relationship between
blood flow in central venous catheters and hemodialysis adequacy.
Clin J Am Soc Nephrol. 2006;1(5):965-971.
511. Niyyar VD, Chan MR. Interventional nephrology: Catheter
dysfunction–prevention and troubleshooting. Clin J Am Soc Nephrol.
2013;8(7):1234-1243.
512. Mokrzycki MH, Lok CE. Traditional and non-traditional strategies
to optimize catheter function: go with more flow. Kidney Int.
2010;78(12):1218-1231.
513. Saran R, Bragg-Gresham JL, Rayner HC, et al. Nonadherence
in hemodialysis: associations with mortality, hospitalization,
and practice patterns in the DOPPS. Kidney Int. 2003;64(1):
254-262.
514. Griffiths RI, Newsome BB, Leung G, Block GA, Herbert RJ,
Danese MD. Impact of hemodialysis catheter dysfunction on dialysis
and other medical services: an observational cohort study. Int J
Nephrol. 2012;2012:673954.
515. Lee T, Barker J, Allon M. Tunneled catheters in hemodialysis
patients: reasons and subsequent outcomes. Am J Kidney Dis.
2005;46(3):501-508.
516. Saran R, Li Y, Robinson B, et al. US Renal Data System
2015 annual data report: epidemiology of kidney disease in the
United States. Am J Kidney Dis. 2016;67(3 Suppl 1); Svii, S1-305.
517. MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M. Central
vein stenosis: a common problem in patients on hemodialysis. Asaio
J. 2005;51(1):77-81.
518. Yuo TH, Chaer RA, Dillavou ED, Leers SA, Makaroun MS.
Patients started on hemodialysis with tunneled dialysis catheter have
similar survival after arteriovenous fistula and arteriovenous graft
creation. J Vasc Surg. 2015;62(6):1590-1597 e1592.
References
S160 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
519. Lee T, Thamer M, Zhang Q, Zhang Y, Allon M. Vascular
access type and clinical outcomes among elderly patients on hemodialysis.
Clin J Am Soc Nephrol. 2017;12(11):1823-1830.
520. Moist LM, Lok CE. Incident dialysis access in patients with
end-stage kidney disease: what needs to be improved. Semin
Nephrol. 2017;37(2):151-158.
521. Manns BJ, Scott-Douglas N, Tonelli M, et al. An economic
evaluation of rt-PA locking solution in dialysis catheters. J Am Soc
Nephrol. 2014;25(12):2887-2895.
522. Ponikvar R, Buturovic-Ponikvar J. Temporary hemodialysis
catheters as a long-term vascular access in chronic hemodialysis
patients. Ther Apher Dial. 2005;9(3):250-253.
523. Bonkain F, Racape J, Goncalvez I, et al. Prevention of
tunneled cuffed hemodialysis catheter-related dysfunction and
bacteremia by a neutral-valve closed-system connector: a singlecenter
randomized controlled trial. Am J Kidney Dis. 2013;61(3):
459-465.
524. Hymes JL, Mooney A, Van Zandt C, Lynch L, Ziebol R,
Killion D. Dialysis catheter-related bloodstream infections: a clusterrandomized
trial of the ClearGuard HD antimicrobial barrier cap. Am
J Kidney Dis. 2017;69(2):220-227.
525. Brunelli SM, Van Wyck DB, Njord L, Ziebol RJ, Lynch LE,
Killion DP. Cluster-randomized trial of devices to prevent catheterrelated
bloodstream infection. J Am Soc Nephrol. 2018;29(4):
1336-1343.
526. Power A, Duncan N, Singh SK, et al. Sodium citrate versus
heparin catheter locks for cuffed central venous catheters: a singlecenter
randomized controlled trial. Am J Kidney Dis. 2009;53:1034-
1041.
527. Hendrickx L, Kuypers D, Evenepoel P, Maes B, Messiaen T,
Vanrenterghem Y. A comparative prospective study on the use of
low concentrate citrate lock versus heparin lock in permanent dialysis
catheters. Int J Artif Organs. 2001;24(4):208-211.
528. Weijmer MC, Van den Dorpel A, Van de Ven PJG, et al.
Randomized, clinical trial comparison of trisodium citrate 30% and
heparin as catheter-locking solution in hemodialysis patients. J Am
Soc Nephrol. 2005;16:2769-2777.
529. Hryszko T, Brzosko S, Mysliwiec M. Low concentration of
heparin used for permanent catheters canal locking is effective and
diminishes the risk of bleeding. Int Urol Nephrol. 2013;45(3):825-
829.
530. Renaud CJ, Lim EK, Tho SJ, Yeoh LY. Effect of ultra-low dose
and standard heparin locks on early tunnelled dialysis catheter outcomes
in low-risk dialysis patients. Nephrology. 2015;20(2):85-90.
531. Hemmelgarn BR, Moist LM, Lok CE, et al. Prevention of
dialysis catheter malfunction with recombinant tissue plasminogen
activator. N Engl J Med. 2011;364(4):303-312.
532. Betjes MG, van Agteren M. Prevention of dialysis catheterrelated
sepsis with a citrate-taurolidine-containing lock solution.
Nephrol Dial Transplant. 2004;19(6):1546-1551.
533. Solomon LR, Cheesbrough JS, Ebah L, et al. A randomized
double-blind controlled trial of taurolidine-citrate catheter locks for
the prevention of bacteremia in patients treated with hemodialysis.
Am J Kidney Dis. 2010;55(6):1060-1068.
534. Filiopoulos V, Hadjiyannakos D, Koutis I, et al. Approaches
to prolong the use of uncuffed hemodialysis catheters: results of a
randomized trial. Am J Neph. 2011;33(3):260-268.
535. Solomon LR, Cheesbrough JS, Bhargava R, et al. Observational
study of need for thrombolytic therapy and incidence of
bacteremia using taurolidine-citrate-heparin, taurolidine-citrate and
heparin catheter locks in patients treated with hemodialysis. Semin
Dial. 2012;25(2):233-238.
536. Malo J, Jolicoeur C, Theriault F, Lachaine J, Senecal L.
Comparison between standard heparin and tinzaparin for haemodialysis
catheter lock. ASAIO J. 2010;56(1):42-47.
537. Abdul-Rahman IS, Al-Howaish AK. Warfarin versus aspirin in
preventing tunneled hemodialysis catheter thrombosis: a prospective
randomized study. Hong Kong J Nephrol. 2007;9(1):23-30.
538. Herrington WG, Nye HJ, Haynes RJ, Winearls CG, Vaux EC.
Does prophylactic anticoagulation reduce the risk of femoral
tunneled dialysis catheter-related complications. J Vasc Access.
2013;14(2):135-142.
539. Mozafar M, Samsami M, Sobhiyeh MR, Jabbehdari S, Fallah
Zavareh M. Effectiveness of aspirin on double lumen permanent
catheter efficacy in ESRD. Nephrourology Monthly. 2013;5(2):762-
765.
540. Wilkieson TJ, Ingram AJ, Crowther MA, et al. Low-intensity
adjusted-dose warfarin for the prevention of hemodialysis catheter
failure: a randomized, controlled trial. Clin J Am Soc Nephrol.
2011;6(5):1018-1024.
541. Coli L, Donati G, Cianciolo G, et al. Anticoagulation therapy
for the prevention of hemodialysis tunneled cuffed catheters (TCC)
thrombosis. J Vasc Access. 2006;7(3):118-122.
542. Lopez-Briz E, Ruiz Garcia V, Cabello JB, Bort-Marti S,
Carbonell Sanchis R, Burls A. Heparin versus 0.9% sodium chloride
intermittent flushing for prevention of occlusion in central venous
catheters in adults. Cochrane Database Syst Rev. 2014;10:
CD008462.
543. Schallom ME, Prentice D, Sona C, Micek ST, Skrupky LP.
Heparin or 0.9% sodium chloride to maintain central venous catheter
patency: a randomized trial. Crit Care Med. 2012;40(6):1820-1826.
544. Oguzhan N, Pala C, Sipahioglu M. Locking tunneled hemodialysis
catheters with hypertonic saline (26% NaCl) and heparin
to prevent catheter-related bloodstream infections and thrombosis:
a randomized, prospective trial. Ren Fail. 2012;34:181-188.
545. Zhong L, Wang HL, Xu B, et al. Normal saline versus heparin
for patency of central venous catheters in adult patients - a systematic
review and meta-analysis. Crit Care. 2017;21(1):5.
546. Godwin JD, Chen JT. Thoracic venous anatomy. Am J
Roentgenol. 1986;147(4):674-684.
547. Chasen MH, Charnsangavej C. Venous chest anatomy:
clinical implications. Eur J Radiol. 1998;27(1):2-14.
548. Haygood TM, Malhotra K, Ng C, Chasen B, McEnery KW,
Chasen M. Migration of central lines from the superior vena cava to
the azygous vein. Clin Radiol. 2012;67(1):49-54.
549. Skandalos I, Hatzibaloglou A, Evagelou I, et al. Deviations of
placement/function of permanent central vein catheters for hemodialysis.
Int J Artif Organs. 2005;28(6):583-590.
550. Beathard GA. Catheter thrombosis. Semin Dial.
2001;14(6):441-445.
551. Besarab A, Pandey R. Catheter management in hemodialysis
patients: delivering adequate flow. Clin J Am Soc Nephrol.
2011;6(1):227-234.
552. Pollo V, Dionizio D, Bucuvic EM, Castro JH, Ponce D.
Alteplase vs. urokinase for occluded hemodialysis catheter: A randomized
trial. Hemodial Int. 2016;20(3):378-384.
553. Tumlin J, Goldman J, Spiegel DM, et al. A phase III, randomized,
double-blind, placebo-controlled study of tenecteplase for
improvement of hemodialysis catheter function: TROPICS 3. Clin J
Am Soc Nephrol. 2010;5(4):631-636.
554. Yaseen O, El-Masri MM, El Nekidy WS, et al. Comparison of
alteplase (tissue plasminogen activator) high-dose vs. low-dose
protocol in restoring hemodialysis catheter function: the ALTEDOSE
study. Hemodial Int. 2013;17(3):434-440.
555. Donati G, Coli L, Cianciolo G, et al. Thrombosis of tunneledcuffed
hemodialysis catheters: treatment with high-dose urokinase
lock therapy. Artifl Organs. 2012;36(1):21-28.
556. Meeus G, Kuypers DR, Claes K, Evenepoel P, Maes B,
Vanrenterghem Y. A prospective, randomized, double-blind crossover
study on the use of 5% citrate lock versus 10% citrate lock in
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S161
permanent hemodialysis catheters. Blood Purif. 2005;23(2):101-
105.
557. Renaud CJ, Leong CR, Bin HW, Wong JCL. Effect of
brachial plexus block-driven vascular access planning on primary
distal arteriovenous fistula recruitment and outcomes. J Vasc Surg.
2015;62(5):1266-1272.
558. Vercaigne LM, Zacharias J, Bernstein KN. Alteplase for
blood flow restoration in hemodialysis catheters: a multicenter, randomized,
prospective study comparing "dwell" versus "push"
administration. Clin Nephrol. 2012;78(4):287-296.
559. Cassidy Jr FP, Zajko AB, Bron KM, Reilly Jr JJ, Peitzman AB,
Steed DL. Noninfectious complications of long-term central venous
catheters: radiologic evaluation and management. AJR Am J
Roentgenol. 1987;149(4):671-675.
560. Oliver MJ, Mendelssohn DC, Quinn RR, et al. Catheter
patency and function after catheter sheath disruption: a pilot study.
Clin J Am Soc Nephrol. 2007;2(6):1201-1206.
561. Xiang DZ, Verbeken EK, Van Lommel AT, Stas M, De
Wever I. Composition and formation of the sleeve enveloping a
central venous catheter. J Vasc Surg. 1998;28(2):260-271.
562. Brismar B, Hardstedt C, Jacobson S. Diagnosis of thrombosis
by catheter phlebography after prolonged central venous
catheterization. Ann Surg. 1981;194(6):779-783.
563. Savader SJ, Ehrman KO, Porter DJ, Haikal LC, Oteham AC.
Treatment of hemodialysis catheter-associated fibrin sheaths by rtPA
infusion: critical analysis of 124 procedures. J Vasc Interv
Radiol. 2001;12(6):711-715.
564. Valliant AM, Chaudhry MK, Yevzlin AS, Astor B, Chan MR.
Tunneled dialysis catheter exchange with fibrin sheath disruption is
not associated with increased rate of bacteremia. J Vasc Access.
2015;16(1):52-56.
565. Lund GB, Trerotola SO, Scheel Jr PF, et al. Outcome of
tunneled hemodialysis catheters placed by radiologists. Radiology.
1996;198(2):467-472.
566. Wong JK, Sadler DJ, McCarthy M, Saliken JC, So CB,
Gray RR. Analysis of early failure of tunneled hemodialysis catheters.
AJR Am J Roentgenol. 2002;179(2):357-363.
567. Wang J, Nguyen TA, Chin AI, Ross JL. Treatment of tunneled
dialysis catheter malfunction: revision versus exchange. J Vasc Access.
2016;17(4):328-332.
568. Duszak Jr R, Haskal ZJ, Thomas-Hawkins C, et al.
Replacement of failing tunneled hemodialysis catheters through preexisting
subcutaneous tunnels: a comparison of catheter function
and infection rates for de novo placements and over-the-wire exchanges.
J Vasc Interv Radiol. 1998;9(2):321-327.
569. Foley RN, Guo H, Snyder JJ, Gilbertson DT, Collins AJ.
Septicemia in the United States dialysis population, 1991 to 1999.
J Am Soc Nephrol. 2004;15(4):1038-1045.
570. Hemmelgarn BR, Moist L, Pilkey RM, et al. Prevention of
catheter lumen occlusion with rT-PA versus heparin (Pre-CLOT):
study protocol of a randomized trial [ISRCTN35253449]. BMC
Nephrol. 2006;7(1):8.
571. Ravani P, Gillespie BW, Quinn RR, et al. Temporal risk
profile for infectious and noninfectious complications of hemodialysis
access. J Am Soc Nephrol. 2013;24(10):1668-1677.
572. Miller LM, Clark E, Dipchand C, et al. Hemodialysis tunneled
catheter-related infections. Can J Kidney Health Dis. 2016;3.
2054358116669129.
573. Axon RN, Engemann JJ, Butcher J, Lockamy K, Kaye KS.
Control of nosocomial acquisition of vancomycin-resistant enterococcus
through active surveillance of hemodialysis patients. Infect
Contr Hosp Epidemiol. 2004;25(5):436-438.
574. Hannah EL, Stevenson KB, Lowder CA, et al. Outbreak of
hemodialysis vascular access site infections related to malfunctioning
permanent tunneled catheters: making the case for active
infection surveillance. Infect Control Hosp Epidemiol. 2002;23(9):
538-541.
575. Patel PR, Yi SH, Booth S, et al. Bloodstream infection rates
in outpatient hemodialysis facilities participating in a collaborative
prevention effort: a quality improvement report. Am J Kidney Dis.
2013;62(2):322-330.
576. Branas P, Morales E, Rios F, et al. Usefulness of endoluminal
catheter colonization surveillance cultures to reduce catheter-related
bloodstream infections in hemodialysis. Am J Infect Control.
2014;42(11):1182-1187.
577. Donlan RM. Biofilm formation: a clinically relevant microbiologic
process. Clin Infect Dis. 2001;33:1387-1392.
578. Saxena AK, Panhotra BR, Al-hafiz AA, Sundaram DS, AbuOyun
B, Al Mulhim K. Cefotaxime-heparin lock prophylaxis against
hemodialysis catheter-related sepsis among Staphylococcus aureus
nasal carriers. Saudi J Kidney Dis Transpl. 2012;23(4):743-754.
579. Mortazavi M, Alsaeidi S, Sobhani R, et al. Successful prevention
of tunneled, central catheter infection by antibiotic lock
therapy using cefotaxime. J Res Med Sci. 2011;16(3):303-309.
580. Saxena AK, Panhotra BR. The impact of catheter-restricted
filling with cefotaxime and heparin on the lifespan of temporary hemodialysis
catheters: a case controlled study. J Nephrol.
2005;18(6):755-763.
581. Saxena AK, Panhotra BR, Sundaram DS, et al. Tunneled
catheters’ outcome optimization among diabetics on dialysis through
antibiotic-lock placement. Kidney Int. 2006;70(9):1629-1635.
582. Saxena AK, Panhotra BR, Sundaram DS, Morsy MN, AlGhamdi
AM. Enhancing the survival of tunneled haemodialysis
catheters using an antibiotic lock in the elderly: a randomised,
double-blind clinical trial. Nephrology. 2006;11(4):299-305.
583. McIntyre CW, Hulme LJ, Taal M, Fluck RJ. Locking of
tunneled hemodialysis catheters with gentamicin and heparin. Kidney
Int. 2004;66(2):801-805.
584. Moran JE, Sun S, Khababa I, Pedan A, Doss S, Schiller B.
A randomized trial comparing gentamicin-citrate and heparin locks
for central venous catheters in maintenance hemodialysis patients.
Am J Kidney Dis. 2012;59:102-107.
585. Nori US, Manoharan A, Yee J, Besarab A. Comparison of
low-dose gentamicin with minocycline as catheter lock solutions in
the prevention of catheter-related bacteremia. Am J Kidney Dis.
2006;48(4):596-605.
586. Zhang P, Yuan J, Tan H, Lv R, Chen J. Successful prevention
of cuffed hemodialysis catheter-related infection using an antibiotic
lock technique by strictly catheter-restricted antibiotic lock solution
method. Blood Purif. 2009;27(2):206-211.
587. Chow KM, Poon YL, Lam MP, Poon KL, Szeto CC, Li PK.
Antibiotic lock solutions for the prevention of catheter-related bacteraemia
in haemodialysis patients. Hong Kong Med J. 2010;16(4):
269-274.
588. Landry DL, Braden GL, Gobeille SL, Haessler SD,
Vaidya CK, Sweet SJ. Emergence of gentamicin-resistant bacteremia
in hemodialysis patients receiving gentamicin lock catheter
prophylaxis. Clin J Am Soc Nephrol. 2010;5(10):1799-1804.
589. Moore CL, Besarab A, Ajluni M, et al. Comparative effectiveness
of two catheter locking solutions to reduce catheter-related
bloodstream infection in hemodialysis patients. Clin J Am Soc
Nephrol. 2014;9(7):1232-1239.
590. Moran J, Sun S, Khababa I, Pedan A, Doss S, Schiller B.
A randomized trial comparing gentamicin/citrate and heparin locks
for central venous catheters in maintenance hemodialysis patients.
Am J Kidney Dis. 2012;59(1):102-107.
591. Moghaddas A, Abbasi MR, Gharekhani A, et al. Prevention
of hemodialysis catheter-related blood stream infections using a
cotrimoxazole-lock technique. Future Microbiol. 2015;10(2):169-
178.
References
S162 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
592. Maki DG, Ash SR, Winger RK, Lavin P. A novel antimicrobial
and antithrombotic lock solution for hemodialysis catheters: a multicenter,
controlled, randomized trial. Crit Care Med.
593. Saxena AK, Panhotra BR, Sundaram DS, Naguib M,
Morsy F, Al-Ghamdi AMA. Enhancing the survival of tunneled hemodialysis
catheters using an antibiotic lock in the elderly: a randomised,
double-blind clinical trial. Nephrology. 2006;11:299-305.
594. Saxena A, Panhotra B, Al-hafiz A, Sundaram D, AbuOyun
B, Al Mulhim K. Cefotaxime-heparin lock prophylaxis against
hemodialysis catheter-related sepsis among Staphylococcus aureus
nasal carriers. Saudi J Kidney Dis Transpl. 2012;23:743-754.
595. Mortazavi M, Alsaeidi S, Sobhani R. Successful prevention
of tunneled, central catheter infection by antibiotic lock therapy using
cefotaxime. J Res Med Sci. 2011;16:303-309.
596. Zhang P, Yuan J, Tan, Lv R, Chen J. Successful prevention of
cuffed hemodialysis catheter-related infection using an antibiotic
lock technique by strictly catheter-restricted antibiotic lock solution
method. Blood Purif. 2009;27:206-211.
597. Moghaddas A, Abbas iM, Gharekhani A. Prevention of hemodialysis
catheter-related blood stream infections using a
cotrimoxazole-lock technique. Future Microbiol. 2015;10:169-178.
598. Maki DG, Ash SR, Winger RK, Lavin P. A novel antimicrobial
and antithrombotic lock solution for hemodialysis catheters: A multicenter,
controlled, randomized trial. Crit Care Med. 2011;39:613-
620.
599. Betjes MGH, van Agteren M. Prevention of dialysis catheterrelated
sepsis with a citrate-taurolidine-containing lock solution.
Nephrol Dial Transplant. 2004;19:1546-1551.
600. Sofroniadou S, Revela I, Smirloglou D. Linezolid versus
vancomycin antibiotic lock solution for the prevention of nontunneled
catheter-related blood stream infections in hemodialysis patients: a
prospective randomized study. Semin Dial. 2012;25:344-350.
601. Al-Hwiesh A. Tunneled catheter-antibiotic lock therapy for
prevention of dialysis catheter-related infections: a single center
experience. Saudi J Kidney Dis Transpl. 2008;19:593-602.
602. Ghazimoghaddam B, Ghazimoghaddam K, Besharat S,
Rajabli M. The role of cefazolin in prophylaxis of central vein catheterrelated
infection in dialysis patients. Pak J Med Sci. 2011;27:1073-
1075.
603. Huddam B, Azak A, Kocak G, Ortabozkoyun L, Duranay M.
The efficacy of prophylactic antibiotics administration prior to
insertion of tunneled catheter in hemodialysis patients. Renal Failure.
2012;34(8):998-1001.
604. Kim SH, Song KI, Chang JW, et al. Prevention of uncuffed
hemodialysis catheter-related bacteremia using an antibiotic lock
technique: a prospective randomized clinical trial. Kidney Int.
2006;69:161-164.
605. Campos R, do Nascimento M, Chula D, Rielaa M. Minocycline-EDTA
lock solution prevents catheter-related bacteremia in
hemodialysis. J Am Soc Nephrol. 2011;22:1939-1945.
606. Kanaa M, Wright M, Akbani H, Laboi P, Bhandar iS,
Sandoe J. Cathasept line lock and microbial colonization of tunneled
hemodialysis catheters: a multicenter randomized controlled trial.
Am J Kidney Dis. 2015;66:1015-1023.
607. Broom J, Krishnasamy R, Hawley C, Playford E, Johnson D.
A randomised controlled trial of Heparin versus EthAnol Lock
THerapY for the prevention of Catheter Associated infecTion in
Haemodialysis patients–the HEALTHY-CATH trial. BMC Nephrol.
2012;13:146.
608. Vercaigne L, Allan D, Armstrong S, Zacharias J, Miller L. An
ethanol/sodium citrate locking solution compared to heparin to
prevent hemodialysis catheter-related infections: a randomized pilot
study. J Vasc Access. 2016;17:55-62.
609. Dogra GK, Herson H, Hutchison B, et al. Prevention of
tunneled hemodialysis catheter-related infections using catheterrestricted
filling with gentamicin and citrate: a randomized
controlled study. J Am Soc Nephrol. 2002;13:2133-2139.
610. Landry DL, Braden GL, Gobeille SL, Haessler SD,
Vaidya CK, Sweet JS. Emergence of gentamicin-resistant bacteremia
in hemodialysis patients receiving gentamicin lock catheter
prophylaxis. Clin J Am Soc Nephrol. 2010;5:1799-1804.
611. Beathard GA, Urbanes A. Infection associated with
tunneled hemodialysis catheters. Semin Dial. 2008;21(6):528-
538.
612. Maki DG, Ash SR, Winger RK, Lavin P, Investigators AT.
A novel antimicrobial and antithrombotic lock solution for hemodialysis
catheters: a multi-center, controlled, randomized trial. Critical
Care Medicine. 2011;39(4):613-620.
613. Krishnasami Z, Carlton D, Bimbo L, et al. Management of
hemodialysis catheter-related bacteremia with an adjunctive antibiotic
lock solution. Kidney Int. 2002;61(3):1136-1142.
614. Poole K. Efflux-mediated multiresistance in Gram-negative
bacteria. Clinical Microbiology and Infection. 2004;10(1):12-26.
615. Beathard GA. Management of bacteremia associated with
tunneled-cuffed hemodialysis catheters. J Am Soc Nephrol.
1999;10(5):1045-1049.
616. Mermel LA, Allon M, Bouza E, et al. Clinical practice
guidelines for the diagnosis and management of intravascular
catheter-related infection: 2009 Update by the Infectious Diseases
Society of America. Clin Infect Dis. 2009;49(1):1-45.
617. Capdevila JA, Segarra A, Planes AM, et al. Successful
treatment of haemodialysis catheter-related sepsis without catheter
removal. Nephrol Dial Transplant. 1993;8(3):231-234.
618. Allon M. Dialysis catheter-related bacteremia: treatment and
prophylaxis. Am J Kidney Dis. 2004;44(5):779-791.
619. Vanherweghem JL, Yassine T, Goldman M, et al. Subclavian
vein thrombosis: a frequent complication of subclavian vein cannulation
for hemodialysis. Clin Nephrol. 1986;26(5):235-238.
620. Schwab SJ, Quarles LD, Middleton JP, Cohan RH,
Saeed M, Dennis VW. Hemodialysis-associated subclavian vein
stenosis. Kidney Int. 1988;33(6):1156-1159.
621. Haage P, Vorwerk D, Wildberger JE, Piroth W, Schurmann K,
Gunther RW. Percutaneous treatment of thrombosed primary arteriovenous
hemodialysis access fistulae. Kidney Int. 2000;57(3):
1169-1175.
622. Toomay S, Rectenwald J, Vazquez MA. How can the complications
of central vein catheters be reduced? central venous
stenosis in hemodialysis patients. Semin Dial. 2016;29(3):201-203.
623. Levit RD, Cohen RM, Kwak A, et al. Asymptomatic central
venous stenosis in hemodialysis patients. Radiology. 2006;238(3):
1051-1056.
624. Renaud CJ, Francois M, Nony A, Fodil-Cherif M, TurmelRodrigues
L. Comparative outcomes of treated symptomatic versus
non-treated asymptomatic high-grade central vein stenoses in the
outflow of predominantly dialysis fistulas. Nephrol Dial Transplant.
2012;27(4):1631-1638.
625. Ozyer U, Harman A, Yildirim E, Aytekin C, Karakayali F,
Boyvat F. Long-term results of angioplasty and stent placement for
treatment of central venous obstruction in 126 hemodialysis patients:
a 10-year single-center experience. AJR Am J Roentgenol.
2009;193(6):1672-1679.
626. Shi Y, Zhu M, Cheng J, Zhang J, Ni Z. Venous stenosis in
chronic dialysis patients with a well-functioning arteriovenous fistula.
Vascular. 2016;24(1):25-30.
627. Massara M, De Caridi G, Alberti A, Volpe P, Spinelli F.
Symptomatic superior vena cava syndrome in hemodialysis patients:
mid-term results of primary stenting. Semin Vasc Surg. 2016;29(4):
186-191.
628. Horikawa M, Quencer KB. Central venous interventions.
Tech Vasc Interv Radiol. 2017;20(1):48-57.
References
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 S163
629. Krishna VN, Eason JB, Allon M. Central venous occlusion in
the hemodialysis patient. Am J Kidney Dis. 2016;68(5):803-807.
630. Yan Y, Sudheendra D, Dagli MS, et al. Effect of central
venous angioplasty on hemodialysis access circuit flow: prospective
study of 25 symptomatic patients. J Vasc Interv Radiol. 2015;26(7):
984-991.
631. Acri I, Carmignani A, Vazzana G, et al. Ipsilateral jugular to
distal subclavian vein transposition to relieve central venous hypertension
in rescue vascular access surgery: a surgical report of 3
cases. Ann Thorac Cardiovasc Surg. 2013;19(1):55-59.
632. Grimm JC, Beaulieu RJ, Sultan IS, Malas MB, Reifsnyder T.
Efficacy of axillary-to-femoral vein bypass in relieving venous hypertension
in dialysis patients with symptomatic central vein occlusion.
J Vasc Surg. 2014;59(6):1651-1656.
633. Allan BJ, Prescott AT, Tabbara M, Bornak A, Goldstein LJ.
Modified use of the Hemodialysis Reliable Outflow (HeRO) graft for
salvage of threatened dialysis access. J Vasc Surg. 2012;56(4):
1127-1129.
634. Davis KL, Gurley JC, Davenport DL, Xenos ES. The use of
HeRo catheter in catheter-dependent dialysis patients with superior
vena cava occlusion. J Vasc Access. 2016;17(2):138-142.
635. Janne d’Othee B, Tham JC, Sheiman RG. Restoration of
patency in failing tunneled hemodialysis catheters: a comparison of
catheter exchange, exchange and balloon disruption of the fibrin
sheath, and femoral stripping. J Vasc Interv Radiol. 2006;17(6):
1011-1015.
636. Merport M, Murphy TP, Egglin TK, Dubel GJ. Fibrin sheath
stripping versus catheter exchange for the treatment of failed
tunneled hemodialysis catheters: randomized clinical trial. J Vasc
Interv Radiol. 2000;11(9):1115-1120.
637. Forauer AR, Theoharis CG, Dasika NL. Jugular vein catheter
placement: histologic features and development of catheter-related
(fibrin) sheaths in a swine model. Radiology. 2006;240(2):427-434.
638. Alomari AI, Falk A. The natural history of tunneled hemodialysis
catheters removed or exchanged: a single-institution experience.
J Vasc Interv Radiol. 2007;18(2):227-235.
639. Mehall JR, Saltzman DA, Jackson RJ, Smith SD. Fibrin
sheath enhances central venous catheter infection. Crit Care Med.
2002;30(4):908-912.
640. Lee T, Qian JZ, Zhang Y, Thamer M, Allon M. Long-term
outcomes of arteriovenous fistulas with unassisted versus assisted
maturation: a retrospective national hemodialysis cohort study. J Am
Soc Nephrol. 2019;30(11):2209-2218.
641. Lok CE. Fistula interventions: less is more. J Am Soc
Nephrol. 2019;30(11):2040-2042.
642. James MT, Conley J, Tonelli M, Manns BJ, MacRae J,
Hemmelgarn BR. Meta-analysis: antibiotics for prophylaxis against
hemodialysis catheter-related infections. Ann Intern Med.
2008;148(8):596-605.
643. Arechabala MC, Catoni MI, Claro JC, et al. Antimicrobial
lock solutions for preventing catheter-related infections in haemodialysis.
Cochrane Database Syst Rev. 2018;4:Cd010597.
644. Yang S, Lok C, Arnold R, Rajan D, Glickman M. Comparison
of post-creation procedures and costs between surgical and an
endovascular approach to arteriovenous fistula creation. J Vasc
Access. 2017;18(Suppl. 2):8-14.
645. Kimball TA, Barz K, Dimond KR, Edwards JM, Nehler MR.
Efficiency of the kidney disease outcomes quality initiative guidelines
for preemptive vascular access in an academic setting. J Vasc Surg.
2011;54(3):760-765. discussion 765-766.
646. Falk A. Maintenance and salvage of arteriovenous fistulas.
J Vasc Interv Radiol. 2006;17(5):807-813.
647. Shenoy S, Woodward RS. Economic impact of the beneficial
effect of changing vascular anastomotic technique in hemodialysis
access. Vasc Endovascular Surg. 2005;39(5):437-443.
648. Perera GB, Mueller MP, Kubaska SM, Wilson SE,
Lawrence PF, Fujitani RM. Superiority of autogenous arteriovenous
hemodialysis access: maintenance of function with fewer secondary
interventions. Ann Vasc Surg. 2004;18(1):66-73.
649. Tangri N, Kitsios GD, Inker LA, et al. Risk prediction models
for patients with chronic kidney disease: a systematic review. Ann
Intern Med. 2013;158(8):596-603.
650. Tangri N, Grams ME, Levey AS, et al. Multinational
assessment of accuracy of equations for predicting risk of kidney
failure: a meta-analysis. JAMA. 2016;315(2):164-174.
651. Drawz PE, Goswami P, Azem R, Babineau DC, Rahman M.
A simple tool to predict end-stage renal disease within 1 year in
elderly adults with advanced chronic kidney disease. J Am Geriatr
Soc. 2013;61(5):762-768.
652. Tangri N, Inker LA, Hiebert B, et al. A dynamic predictive model
for progression of CKD. Am J Kidney Dis. 2017;69(4):514-520.
653. Tangri N, Stevens LA, Griffith J, et al. A predictive model for
progression of chronic kidney disease to kidney failure. JAMA.
2011;305(15):1553-1559.
654. Zoccali C. Moderator’s view: Predictive models: a prelude to
precision nephrology. Nephrol Dial Transplant. 2017;32(5):756-758.
655. Lynch JR, Wasse H, Armistead NC, McClellan WM.
Achieving the goal of the Fistula First breakthrough initiative for
prevalent maintenance hemodialysis patients. Am J Kidney Dis.
2011;57(1):78-89.
656. Xue H, Lacson Jr E, Wang W, Curhan GC, Brunelli SM.
Choice of vascular access among incident hemodialysis patients: a
decision and cost-utility analysis. Clin J Am Soc Nephrol.
2010;5(12):2289-2296.
657. Drew DA, Lok CE, Cohen JT, Wagner M, Tangri N,
Weiner DE. Vascular access choice in incident hemodialysis patients:
a decision analysis. J Am Soc Nephrol. 2015;26(1):183-
191.
658. Hiremath S, Knoll G, Weinstein MC. Should the arteriovenous
fistula be created before starting dialysis?: a decision analytic
approach. PLoS One. 2011;6(12):e28453.
659. Tamura MK, Tan JC, O’Hare AM. Optimizing renal replacement
therapy in older adults: a framework for making individualized
decisions. Kidney Int. 2012;82(3):261-269.
660. Lok CE, Allon M, Moist L, Oliver MJ, Shah H, Zimmerman D.
Risk equation determining unsuccessful cannulation events and
failure to maturation in arteriovenous fistulas (REDUCE FTM I). J Am
Soc Nephrol. 2006;17(11):3204-3212.
661. Fissell RB, Fuller DS, Morgenstern H, et al. Hemodialysis
patient preference for type of vascular access: variation and predictors
across countries in the DOPPS. J Vasc Access. 2013;14(3):
264-272.
662. Keating PT, Walsh M, Ribic CM, Brimble KS. The impact of
patient preference on dialysis modality and hemodialysis vascular
access. BMC Nephrol. 2014;15:38.
663. Xi W, Harwood L, Diamant MJ, et al. Patient attitudes towards
the arteriovenous fistula: a qualitative study on vascular access
decision making. Nephrol Dial Transplant. 2011;26(10):3302-
3308.
664. Casey JR, Hanson CS, Winkelmayer WC, et al. Patients’
perspectives on hemodialysis vascular access: a systematic review
of qualitative studies. Am J Kidney Dis. 2014;64(6):937-953.
665. Lok CE. Avoiding trouble down the line: the management
and prevention of hemodialysis catheter-related infections. Adv
Chronic Kidney Dis. 2006 Jul;13(3):225-244.
666. Valenti D, Mistry H, Stephenson M. A novel classification
system for autogenous arteriovenous fistula aneurysms in renal access
patients. Vasc Endovasc Surg. 2014;48(7-8):491-496.
667. Wilson NA, Shenoy S. Managing ‘buttonhole’ complications.
J Vasc Access. 2014;15(7 Suppl):91-95.
References
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