When to place permanent dialysis access in Chronic Kidney Disease (CKD)?

From the Guidelines

Permanent dialysis access should be placed when a patient with chronic kidney disease (CKD) has an estimated glomerular filtration rate (eGFR) of less than 20-25 mL/min/1.73m² and is expected to require dialysis within the next 6-12 months, as recommended by the most recent guidelines 1.

Key Considerations

• The timing of access placement should be individualized based on the rate of kidney function decline, with patients experiencing rapid progression (>5 mL/min/year decrease in eGFR) requiring earlier access planning 1.
• Clinical indicators that suggest the need for access placement include worsening uremic symptoms, difficult-to-control hypertension, volume overload resistant to diuretics, and persistent electrolyte abnormalities 1.
• Nephrologists typically monitor these parameters along with laboratory values like creatinine, BUN, potassium, and bicarbonate levels to determine optimal timing 1.
• Early access planning is crucial because it reduces the need for temporary catheters, which carry higher infection risks and mortality rates 1.

Access Type and Timing

• Arteriovenous fistulas (AVFs) should be created at least 3-6 months before anticipated dialysis initiation to allow adequate maturation time 1.
• Arteriovenous grafts (AVGs) need about 2-3 weeks to heal before use 1.
• Peritoneal dialysis catheters should be placed 2-4 weeks before anticipated use to allow for healing of the exit site 1.

Benefits of Early Access Planning

• Reduces the need for temporary catheters and associated complications 1.
• Allows for timely creation and maturation of permanent access, reducing the risk of access-related morbidity and mortality 1.
• Improves patient outcomes and quality of life by enabling timely initiation of dialysis therapy 1.

From the Research

Timing of Permanent Dialysis Access Placement

• Permanent dialysis access should be placed when the patient's estimated glomerular filtration rate (GFR) is less than 20 ml/min 2
• The access should be placed at least 6 months before the start of hemodialysis (HD) in the case of native arteriovenous (AV) fistulae and 3-6 weeks before in the case of synthetic AV grafts 2
• Patients with chronic kidney disease (CKD) should be referred for hemodialysis access when their estimated GFR progressively decreases to 15 to 20 mL/min, or when their peritoneal dialysis, kidney transplant, or current vascular access is failing 3

Patient Evaluation and Preparation

• Early referral of patients with advanced CKD (GFR <or= 30 ml/min: CKD stage 4) is necessary for education about different modalities of kidney replacement therapy and to allow sufficient time for permanent functioning vascular access placement before HD initiation 2
• Patients should limit or avoid vascular procedures that may complicate future arteriovenous access, such as antecubital venipuncture or peripheral insertion of central catheters 3

Type and Location of Permanent Vascular Access

• A native AV fistula is the preferred type of vascular access, with a wrist (radial-cephalic) primary AV fistula being the first choice 2
• The location of the vascular access should be chosen based on patient anatomy and preferences, with the goal of preserving vein integrity for future access sites 4

Maturation and Care of Vascular Access

• A native AV fistula should not be used for at least 6-8 weeks after placement to allow for maturation 2
• Patients should be educated on the importance of protecting their vascular access and recognizing signs of complications, such as infection or thrombosis 3