From the Guidelines
The current KDIGO guidelines recommend a patient-centered approach to vascular access selection, emphasizing the development of an ESKD Life-Plan that considers individual patient needs and preferences, with a focus on reliable, complication-free access to deliver prescribed dialysis. The guidelines, as outlined in the 2019 update 1, prioritize a comprehensive evaluation of the patient's lifetime with ESKD and kidney replacement therapy options, taking into account factors such as age, comorbidities, vascular anatomy, and patient preference.
Key Recommendations
- The guidelines de-emphasize the need for AV access surveillance, instead emphasizing the importance of improved training and application of vascular access monitoring 1.
- The creation of vascular accesses, care and management of each type of vascular access, and prevention and treatment of complications are all addressed in the guidelines, with a focus on high-quality standards 1.
- The guidelines present three primary targets for use in tracking performance, including the development of a regularly updated Life-Plan for each patient, and targets to limit major known complications associated with each access type 1.
Rationale
The guidelines are based on a comprehensive review of the evidence, using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks 1. The guidelines aim to support multidisciplinary care providers in meeting the dialysis access needs of individual patients, with a focus on improving patient outcomes and quality of life.
Implementation
The guidelines recommend a multidisciplinary approach to vascular access care, with regular monitoring of access function and prompt intervention for dysfunction. The development of an ESKD Life-Plan is essential, as it allows for a comprehensive evaluation of the patient's needs and preferences, and enables healthcare providers to make informed decisions about vascular access selection and management. By following these guidelines, healthcare providers can improve patient outcomes, reduce complications, and enhance quality of life for patients with ESKD.
From the Research
Current KDIGO Guidelines for Dialysis Access
The current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for dialysis access recommend the following:
- Arteriovenous fistula (AVF) as the first choice for chronic hemodialysis due to its longevity and lower association with morbidity and mortality 2
- Arteriovenous graft (AVG) as the second option when AVF is not possible 3, 4
- Central venous catheter (CVC) as a last resort or for temporary use, due to its higher risk of complications such as infection and thrombosis 2, 5
Key Considerations
- The choice of dialysis access type should be individualized based on patient characteristics and medical history 3, 6
- A multidisciplinary team approach is recommended for vascular access management, including nephrologists, radiologists, vascular surgeons, and dialysis staff 2
- Regular monitoring and maintenance of vascular access are crucial to prevent complications and ensure optimal dialysis outcomes 2, 3