2006 Updates Clinical Practice Guidelines and Recommendations

Foreword
The publication of the second update of the Clinical Practice Guidelines (CPGs) and Clinical
Practice Recommendations (CPRs) for Vascular Access represents the second update
of these guidelines since the first guideline on this topic was published in 1997. The first
set of guidelines established the importance of placing fistulae in long-term hemodialysis
patients. Several of these guidelines have been selected as clinical performance measures
by regulatory agencies to drive the process of quality improvement in long-term dialysis
patients, and an initiative in the United States called “Fistula First” recently was started in
an effort to increase the percentage of patients who have an arteriovenous fistula placed
for long-term hemodialysis therapy.
Several major changes have occurred since the publication of the first set of guidelines.
First, a number of clinical trials have been performed to determine the efficacy of
different methods of identifying an access that is beginning to fail. Thus, this update of
the guideline includes a substantial revision of accepted methods for access dysfunction
detection. Second, cannulation techniques have been updated to include the importance
of training staff in cannulation techniques and the appropriate uses of the buttonhole
technique for arteriovenous fistulae. Finally, urokinase was removed from the market and
other thrombolytic agents have been developed to assist with reestablishing patency in
dialysis catheters. The use of these newer agents is addressed in this update.
This document has been divided into 3 major areas. The first section consists of guideline
statements that are evidence based. The second section is a new section that consists
of opinion-based statements that we are calling “clinical practice recommendations,” or
CPRs. These CPRs are opinion based and are based on the expert consensus of the Work
Group members. It is the intention of the Work Group that the guideline statements in
Section I can be considered for clinical performance measures because of the evidence
that supports them. Conversely, because the CPRs are opinion based, and not evidence
based, they should not be considered to have sufficient evidence to support the development
of clinical performance measures. The third section consists of research recommendations
for these guidelines and CPRs. We have decided to combine all the research
recommendations for the guidelines into 1 major section and also have ranked these recommendations
into 3 categories: critical importance, high importance, and moderate importance.
Our intended effect of this change in how the research recommendations are
presented is to provide a guidepost for funding agencies and investigators to target research
efforts in areas that will provide important information to benefit patient outcomes.
This final version of the Clinical Practice Guidelines and Recommendations for Vascular
Access has undergone extensive revision in response to comments during the public
review. While considerable effort has gone into their preparation during the past 2
years and every attention has been paid to their detail and scientific rigor, no set of guidelines
and clinical practice recommendations, no matter how well developed, achieves its
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