The National Kidney Foundation has released an update to its Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines for vascular access in patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Published in the American Journal of Kidney Diseases and available for free online at www.ajkd.org, the guidelines provide a completely revamped set of 26 individual recommendations that focus on dialysis access choices and management. They are tailored to individual patient’s goals and access needs, with the objective of enhancing clinical outcomes.
“It has been over a decade since the last KDOQI guidelines for vascular access were updated in 2006,” says Charmaine E. Lok, MSc, MD, FRCPC, who chaired the workgroup that developed the update. “The previous guidelines promoted a ‘fistula first’ approach to access choice and encouraged use of arteriovenous access surveillance, but this resulted in some unintended consequences. Clinicians and patients became frustrated with high rates of fistula failure and the need for multiple interventions to facilitate and salvage access. The current guidelines were inspired by the need to re-evaluate and refine our prior approaches to vascular access care and management.”
For the update, an evidence review team from the University of Minnesota and a KDOQI workgroup reviewed more than 4,600 peer-reviewed publications, 286 of which were included in evidence tables. The workgroup included a wide range of experts in vascular access, including clinical and academic-based adult and pediatric nephrologists, interventional nephrologists, radiologists, surgeons, and vascular access nurses. “We incorporated more rigorous data, used contemporary guideline methodology, and applied the resultant guidelines at both population and patient levels,” Dr. Lok says.
The updated KDOQI guidelines offer many important updates and reinforce several areas of previous guideline statements. An important practice introduced and emphasized in the update is taking a more patient-focused approach for those with ESKD. The ESKD Life-Plan was unveiled, encouraging a comprehensive evaluation of the patient’s lifetime with ESKD and kidney replacement therapy options (Figure).
The ESKD Life-Plan is achieved by creating a “P-L-A-N” for each patient that considers the Patient’s Life-Plan first and corresponding Access Needs. For each access, the “Access Needs” part of P-L-A-N includes designing and documenting the patient’s access creation plan, contingency plan, succession plan, and underlying vessel preservation plan. “This comprehensive plan for Access Needs can be remembered as ViP ACCeS plans: Vessel important Preservation, Access Creation, Contingency, and ESKD access Succession plans,” says Dr. Lok.
The overarching goal of the vascular access guidelines is to help patients to achieve reliable, functioning, and complication-free dialysis access while preserving future dialysis access site options as required. The ESKD Life-Plan is a central concept to facilitate this goal. “The ESKD Life-Plan is a strategy for living with ESKD and is ideally made by a multidisciplinary CKD management team, with the patient serving as a key team player,” Dr. Lok says. “The ESKD Life-Plan begins in the pre-dialysis period and encompasses a continuum-of-care model from CKD to ESKD. It individualizes plans for ESKD modalities while concurrently considering the dialysis access strategy.”
The ESKD Life-Plan takes into consideration the needs and preferences of patients when choosing an access and planning up front for the likely complications and remediations of the current access, along with transition plans to the next access. The guideline recommends patients receive an individualized ESKD Life-Plan that is regularly reviewed, updated, and documented on their medical record. “Once the P-L-A-N is in place, the hope is clinicians can facilitate ‘the right access, in the right patient, at the right time, for the right reason’ to truly achieve a personalized, patient-centered approach,” Dr. Lok says.
According to Dr. Lok, the updated guidelines are elastic in that they leave open opportunities to change with new data and research. “We continue to search for ways to improve vascular access care safely, with the patient being our primary focus,” she says. “A critical aspect of the new guidelines is each of the 26 recommendations has a dedicated section on suggested future research topics. The hope is that clinical and research communities in nephrology and dialysis access embrace these suggestions to conduct studies that provide strong evidence in the development of future vascular access guidelines.”
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. Available at: https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext. A press release is available at: https://www.kidney.org/news/national-kidney-foundation-releases-comprehensive-guideline-vascular-access-dialysis-patients.
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