2006 Updates Clinical Practice Guidelines and Recommendations

ate of usable fistula accesses. This shift in emphasis is important to minimize wasted time
and effort and reduce the primary failure rate and salvage procedures.
A number of barriers need to be overcome to achieve the goals set for vascular fistula
construction; chief among these is the late referral of patients for permanent access
placement, reflected in patient hospitalizations. In some regions, up to 73% of patients
are hospitalized for initiation of HD therapy, almost invariably for dialysis catheter access
placement. 21 Unexpectedly, the modest increases in fistula use rates have been accompanied
by increases in the use of catheters. 2 Early referral of patients with CKD stage 5
to a nephrologist is absolutely essential to allow for access planning and thus increase the
probability of fistula construction and maturation, thereby decreasing the need for
catheter placement.
To achieve these objectives, the current Work Group has developed and revised the
vascular access practice guidelines and strategies for implementation and has made a concerted
effort to differentiate guidelines from recommendations. At the core of these
guidelines is the goal of early identification of patients with progressive kidney disease
and the identification and protection of potential fistula construction sites—particularly
sites using the cephalic vein—by members of the health care team and patients.
After access has been constructed, dialysis centers need to use a multifaceted continuous
quality improvement (CQI) program to detect vascular accesses at risk, track access
complication rates, and implement procedures that maximize access longevity. Vascular
access databases that are available to all members of the vascular access team (VAT) are
crucial. The Work Group has developed explicit guidelines regarding which tests to use
to evaluate a given access type and when and how to intervene to reduce thrombosis and
underdialysis. The Work Group believes that the guidelines are reasonable, appropriate,
and achievable. Attainment of these goals will require the concerted efforts of not only
practicing nephrologists, but also nephrology nurses, access surgeons, vascular interventionalists,
patients, and other members of the health care team.
In this update of the Vascular Access Guidelines, the Work Group did not perform a
comprehensive review of all the guidelines. Seven topics underwent systematic review,
and these are identified. The other guidelines were unified and consolidated. More recent
references, including reviews, were included when appropriate.
KDOQI National Kidney Foundation 243