From the Guidelines
Patients with chronic kidney disease (CKD) should be referred for permanent dialysis access creation when their estimated glomerular filtration rate (eGFR) falls below 15-20 mL/min/1.73m², as supported by a well-conducted simulation study 1. This recommendation is based on the latest guideline update from the American Journal of Kidney Diseases, which emphasizes the importance of timely referral for vascular access creation to avoid unnecessary procedures and ensure a functional access at dialysis initiation. Key considerations for referral include:
- eGFR threshold of 15-20 mL/min/1.73m² 1
- Time frame of 6-9 months before anticipated dialysis start to allow for access creation and maturation 1
- Patient and process-of-care factors, such as vascular anatomy, diabetes, and peripheral vascular disease, which may complicate access creation 1
- Clinical indicators, including rapidly declining kidney function, uremic symptoms, and refractory fluid overload, which should prompt referral for permanent access creation. The goal of early referral is to avoid the need for temporary central venous catheters, which are associated with higher risks of infection and other complications, and to improve long-term outcomes, including access patency rates and reduced morbidity and mortality 1.
From the Research
Referral Timing for Permanent Dialysis Access
The optimal time for referring a Chronic Kidney Disease (CKD) patient for permanent dialysis access is a crucial decision. According to 2, the timing of arteriovenous fistula (AVF) referral is uncertain, but improving the timeliness of referral may reduce central venous catheter (CVC) use.
- A 15-month referral time frame resulted in 34% of patients with incident CVCs, 14% with unnecessary AVFs, and a life expectancy of 1,751 days.
- Referral at an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73 m(2) gave 38% with incident CVCs, 20% with unnecessary AVFs, and life expectancy of 1,742 days.
- Using an eGFR threshold of 15 mL/min/1.73 m(2) resulted in 10% of patients having an unnecessary AVF.
Considerations for Referral
The decision to refer a CKD patient for permanent dialysis access should consider the individual's rate of CKD progression and age.
- For fast progressors, referral at an eGFR of 25 mL/min/1.73 m(2) achieved a similar incident CVC percentage as referral at 15 mL/min/1.73 m(2) in slower progressors 2.
- Elderly patients with CKD could be referred later to reduce the risk of creating an AVF that is never used 2.
- Patients with an eGFR < 15 mL/min/1.73 m(2) may benefit from an arteriovenous graft (AVG) rather than an AVF to reduce catheter use at dialysis initiation 3.
Vascular Access Strategies
The choice of vascular access strategy, including AVF or AVG, depends on various factors, including patient age, CKD progression, and vascular anatomy.
- A randomized controlled trial is currently underway to compare the clinical outcomes of AVF and AVG in older adults with end-stage kidney disease 4.
- Preserving peripheral veins, central veins, and peripheral arteries is crucial for creating a functioning AVF 5.
- An individualized strategy, known as Patient Life-Plan, Access Needs, or PLAN, should be developed for each patient, including contingency plans for access failure 6.