Vascular Access

Publication Date: March 1, 2020
Last Updated: January 31, 2023

GUIDELINE STATEMENTS

Patient First: ESKD Life-Plan

ESKD Life-Plan and Vascular Access Choice

KDOQI considers it reasonable that each patient with progressive CKD and/or with an eGFR 15-20 mL/min/1.73 m2 or already on kidney replacement therapy should have an individualized ESKD Life-Plan that is regularly reviewed, updated, and documented on their medical record. (Expert Opinion)
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KDOQI considers it reasonable to conduct an annual review and update of each patient’s individualized ESKD Life-Plan, together with their health care team. (Expert Opinion, )
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KDOQI considers it reasonable that, in addition to regular monitoring, a minimum quarterly overall review and update of each patient’s vascular access functionality, complication risks, and potential future dialysis access options be done together with their health care team. (Expert Opinion, )
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Vascular Access Types

AV Access: Indications for Use

KDOQI considers it reasonable to have an AV access (AVF or AVG) in a patient requiring HD, when consistent with their ESKD Life-Plan and overall goals of care. (Expert Opinion)
Note: See specific sections on incident and prevalent patients and the choice of AV access type and their appropriate locations.
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Central Venous Catheters (CVC): Indications for Use

KDOQI considers it reasonable in valid clinical circumstances to use tunneled CVCs for short-term or long-term durations for incident patients, as follows. (Expert Opinion)
Short-term duration:
  • AVF or AVG created but not ready for use and dialysis is required
  • Acute transplant rejection or other complications requiring dialysis 
  • PD patient with complications that require time-limited peritoneal rest or resolution of complication (eg, pleural leak)
  • Patient has a living donor transplant confirmed with an operation date in the near future (eg, < 90 days) but requires dialysis
  • AVF or AVG complication such as major infiltration injury or cellulitis that results in temporary nonuse until problem is resolved
Note: In special, limited circumstances where temporary CVC is required to manage a vascular access complication (eg, <2 weeks), it may be acceptable to use a nontunneled CVC.

Long-term or indefinite duration:
  • Multiple prior failed AV accesses with no available options (see anatomic restrictions below)
  • Valid patient preference whereby use of an AV access would severely limit QOL or achievement of life goals and after the patient has been properly informed of patient-specific risks and benefits of other potential and reasonable access options for that patient (if available)
  • Limited life expectancy
  • Absence of AV access creation options due to a combination of inflow artery and outflow vein problems (eg, severe arterial occlusive disease, noncorrectable central venous outflow occlusion) or in infants/children with prohibitively diminutive vessels 
  • Special medical circumstances
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Vascular Access for Incident Patients

The statements below are in the context of the ESKD Life-Plan and associated Access Algorithms and their considerations, such as patient comorbidities, circumstances, etc.
KDOQI suggests an AV access (AVF or AVG) in preference to a CVC in most incident and prevalent HD patients due to the lower infection risk associated with AV access use. (Conditional (weak)  “We suggest”, Low)
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KDOQI considers it reasonable that the choice of AV access (AVF or AVG) be based on the operator’s/clinician’s best clinical judgment that considers the vessel characteristics, patient comorbidities, health circumstances, and patient preference.
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KDOQI suggests that if sufficient time and patient circumstances are favorable for a mature, usable AVF, such a functioning AVF is preferred to an AVG in incident HD patients due to fewer long-term vascular access events (eg, thrombosis, loss of primary patency, interventions) associated with unassisted AVF use. (Conditional (weak)  “We suggest”, Low)
Notes:
  • Patient circumstances refer to vessel characteristics, patient comorbidities, health circumstances, and patient preference.
  • Unassisted AVF use refers to an AVF that matures and is used without the need for endovascular or surgical interventions, such as angioplasty. A preplanned vessel superficialization is acceptable and not considered an additional intervention.
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KDOQI suggests that most incident HD patients starting dialysis with a CVC should convert to either an AVF or AVG, if possible, to reduce their risk of infection/bacteremia, infection-related hospitalizations, and adverse consequences. (Conditional (weak)  “We suggest”)
(Very Low–Moderate Quality of Evidence)
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There is inadequate evidence for KDOQI to make recommendations on choice of incident vascular access type based on associations with all-cause hospitalizations or mortality. (Expert Opinion, Insufficient)
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There is inadequate evidence for KDOQI to make a recommendation on choice of AVF vs AVG for incident vascular access based on associations with infections, all-cause hospitalizations, or patient mortality.

(, Insufficient)
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There is inadequate evidence for KDOQI to make a recommendation for incident HD patients using a CVC on converting to an AV access (AVF or AVG) within the first year of dialysis initiation, solely to reduce their risk of mortality. (, Insufficient)
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KDOQI considers it reasonable to use tunneled CVC in preference to nontunneled CVC due to the lower infection risk with tunneled CVC. (Expert Opinion)
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KDOQI considers it reasonable to use nontunneled internal jugular CVC only for temporary purposes for a limited time period (<2 weeks or per individual facility policy) to limit infection risk. (Expert Opinion, )
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Vascular Access in Prevalent HD Patients

There is inadequate evidence for KDOQI to make a recommendation on the type of vascular access preferred in prevalent HD patients based on vascular access outcomes, patient hospitalizations, or mortality. (-, Insufficient)
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KDOQI considers it reasonable that prevalent HD patients use an AV access (AVF or AVG) in preference to a CVC, if possible, due to the association with lower vascular access–related events (eg, infection, thrombotic, and nonthrombotic complications). (Expert Opinion)
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KDOQI considers it reasonable that if clinical circumstances are favorable for a mature, usable AVF, such a functioning AVF is preferred to AVG in prevalent HD patients.
Note: Clinical circumstances refer to patient’s vessel characteristics, comorbidities, health circumstances, potential exposure time to CVC use, and patient preference.
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KDOQI considers it reasonable in valid clinical circumstances to use tunneled CVCs for short-term or long-term durations for prevalent patients, as follows: (Expert Opinion)
Short-term duration:
  • AVF or AVG created but not ready for use and dialysis is required 
  • Acute transplant rejection or other complications requiring dialysis 
  • PD patient with complications that require time-limited peritoneal rest or resolution of complication (eg, pleural leak) 
  • Patient has a living donor transplant confirmed with an operation datein the near future (eg,<90 days) but requires dialysis 
  • AVF or AVG complication such as major infiltration injury or cellulitis that results in temporary nonuse until problem is resolved
Note: In special, limited circumstances where temporary CVC is required to manage a vascular access complication (eg, <2 weeks), it may be acceptable to use a nontunneled CVC.

Long-term or indefinite duration:
  • Multiple prior failed AV accesses with no available options (see anatomic restrictions below) 
  • Valid patient preference whereby use of an AV access would severely limit QOL or achievement of life goals and after the patient has been properly informed of patient-specific risks and benefits of other potential and reasonable access options for that patient (if available) 
  • Limited life expectancy 
  • Absence of AV access creation options due to a combination of inflow artery and outflow vein problems (eg, severe arterial occlusive disease, noncorrectable central venous outflow occlusion) or in infants/children with prohibitively diminutive vessels 
  • Special medical circumstances
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Vascular Access Locations

AV Access Locations

The statements below are in the context of the ESKD Life-Plan and associated Access Algorithms and their considerations (eg, feasible anatomy, etc). This section refers to AVF or AVG.
KDOQI considers it reasonable to choose the site (location) of the AV access (AVF or AVG) after careful consideration of the patient’s ESKD Life-Plan, potentially following the below paths. (Expert Opinion)
A) A patient’s ESKD Life-Plan includes an anticipated long duration (eg, >1 year on HD): 
  • Forearm AVF (snuffbox or distal radiocephalic or transposed radiobasilic) Summary of Guideline Statements S22 AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020 
  • Forearm loop AVG or proximal forearm AVF (eg, proximal radiocephalic, proximal vessel, and perforator combinations) or brachiocephalic, per operator discretion 
  • Brachiobasilic AVF or upper arm AVG, per operator discretion

B) A patient’s ESKD Life-Plan includes an anticipated limited duration (eg, 1 year) on HD:
  • Forearm loop AVG or brachiocephalic AVF (with high likelihood of unassisted maturation) 
  • Upper arm AVG

C) A patient urgently starts HD without prior sufficient time to plan for and/or create an AV access and has an anticipated limited duration (eg, 1 year) on HD:
  • Early or standard cannulation loop AVG (forearm or upper arm location), or CVC, per operator discretion and patient’s clinical needs
Note: The choice of upper extremity location of an AVG should be based on the operator’s discretion and best clinical judgment considering the patient’s ESKD Life-Plan, due to inadequate evidence to demonstrate a difference between forearm versus upper arm AVG patency or complication outcomes (including infections, hospitalizations, and mortality).

D) A patient urgently starts HD without prior sufficient time to plan for and/or create an AV access and has an anticipated long duration (eg, >1 year) on HD:
  • PD catheter if PD not a long-term option or 
  • Forearm early cannulation loop graft. When AVG fails or 
  • CVC if high likelihood of rapid AVF maturation and usability success
E) All AV access options in the upper extremity have been exhausted and patient’s ESKD Life-Plan includes a long duration (eg, >1 year) on HD, the following may be considered based on individual patient circumstances and operator’s best clinical judgment and expertise: 
  • Lower extremity AVF or AVG or HeRO Graft (Merit Medical)
While a suggested stepwise approach to AV access site selection is provided, modification of the approach is encouraged as necessary to consider the individual’s ESKD Life-Plan and circumstances, and follow the below key principles, given available suitable vessels: 
  • Distal first to proximal next approach 
  • Always preserve the integrity of vessels for future vascular access options 
  • Nondominant extremity in preference to dominant, only if choices are equivalent
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CVC Locations

KDOQI considers it reasonable to choose the site (location) of the CVC after careful consideration of the patient’s ESKD LifePlan as follows:
  • Upper extremity before lower extremity, only if choices are equivalent
  • There are valid reasons for CVC use and its duration of use is expected to be limited (eg, <3 months):
    • AV access is likely to be ready for use in near future—consider preferential use of tunneled cuffed CVC in opposite extremity to anticipated AV access 
    • Transplant is anticipated in near future (ie, preserve iliac vessels)—consider preferential use of tunneled cuffed right IJ catheter
Note: See below guidance for more details on CVC location
  • Some experts support that in urgent dialysis start situations, under limited use circumstances (eg, <1 month) and transplant is not an option, use of a tunneled, cuffed femoral CVC is acceptable (unless contraindicated) until the AV access or PD catheter can be quickly created and used. Use of the femoral vein preserves the upper extremity vessels for future AV access creation.
Note: Contraindications to femoral vein CVC include femoral or iliac vessel pathology or prior surgery/reconstruction; hygienic reasons (eg, chronic unresolved diarrhea), morbid obesity (BMI > 35 kg/m2 ), or other difficult vein access.
  • When there are valid reasons for CVC use and duration of use is expected to be prolonged (eg, >3 months) without anticipated use of AV access, CVC may be placed in the following locations in order of preference: 
    • Internal jugular 
    • External jugular 
    • Femoral 
    • Subclavian 
    • Lumbar
Note: In the absence of contraindications, prior pathology (eg, central stenosis) or intervention (eg, pacemaker) CVC insertion on the right side is preferable to the left side due to more direct anatomy. If one side has pathology that limits AV access creation but allows for CVC insertion, this side should be used for the CVC to preserve the other side for AV access creation. (Expert Opinion)
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AV Access Types and Materials

Novel AV Access Types and Materials

KDOQI suggests that the choice of material for an AVG should be based on the nephrologist’s or operator’s discretion and best clinical judgment since the current evidence does not demonstrate that one graft material or modification thereof is associated with improved outcomes in terms of patency or complications. (Conditional (weak)  “We suggest”, Low)
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KDOQI considers it reasonable to use early cannulation grafts as a CVC-sparing strategy in appropriate patients, considering their ESKD Life-Plan. (Expert Opinion)
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CVC Configuration and Materials

Configuration and Materials

KDOQI suggests that the choice of tunneled HD CVC type and design be based on the clinician’s discretion and best clinical judgment. (Conditional (weak)  “We suggest”, Low)
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Timing, Preparation, and Planning for Creation/Insertion of Dialysis Access

Education on ESKD Modalities and Dialysis Access

KDOQI considers it reasonable for adult and pediatric patients with an eGFR ≤30 mL/min/1.73 m2 (CKD G4) with progressive decline in kidney function to be educated on all modalities of kidney replacement therapy (KRT) options, including transplantation, so that timely referral can be made for the appropriate modality and creation of a functional dialysis access, if necessary. (Expert Opinion)
Note: For pediatric patients, calculate eGFR by Schwartz formula.
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KDOQI considers it reasonable for adult and pediatric patients with a kidney transplant with an eGFR ≤ 30 mL/min/1.73 m2 (CKD G4) with progressive decline in kidney function, to be educated on all modalities of KRT options, including potential re-transplantation, so that timely referral can be made for the appropriate modality and creation of a functional dialysis access, if necessary. A re-review of the patient’s ESKD Life-Plan should occur.
Note: For pediatric patients, calculate eGFR by Schwartz formula.
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KDOQI considers it reasonable for PD patients with complications refractory to therapy and/or with circumstances that make PD less conducive than HD to be educated on all kidney transplant and HD options, so that timely referral can be made for the appropriate modality preparation and creation of a functional dialysis access, if necessary. A re-review of the patient’s ESKD Life-Plan should occur. (Expert Opinion)
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KDOQI considers it reasonable and important to ensure that the predetermined dialysis access is usable to provide the prescribed dialysis when the patient is ready to initiate the planned dialysis (eg, an AV access is mature and ready for cannulation for HD). (Expert Opinion)
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KDOQI considers it reasonable that in patients who have unplanned or urgent dialysis starts with a CVC, the ESKD Life-Plan is established with a dialysis access plan within 30 days of dialysis start. (Expert Opinion)
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Referral for AV Access

In some facilities, referral of the patient for assessment by the vascular access team/surgeon for appropriate dialysis access is a different process than referral for the actual creation/insertion. However, for simplicity, the Guideline recommendations have been combined, keeping in mind variable timeframes between assessment for and creation of vascular access.
Nondialysis CKD Patients
KDOQI considers it reasonable that in nondialysis CKD patients with progressive decline in kidney function, referral for dialysis access assessment and subsequent creation should occur when eGFR is 15-20 mL/min/1.73 m2 . Earlier referral should occur in patients with unstable and/or rapid rates of eGFR decline (eg, >10 mL/min/year).
Note: Nondialysis CKD patients include those with a failing transplant.
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Hemodialysis Patients
KDOQI considers it reasonable that in HD patients with recurrent vascular access problems, prompt referral for assessment and creation of a new AV access should be made to allow adequate time for specialist consult and follow-up, as well as possible AV access failure and correction, and should consider individual patient circumstances and competing risk of death. (Expert Opinion)
Note: Recurrent vascular access problems include recurrent need for CVC use and/or ≥3 corrective interventions/6 months.
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When PD Is the Modality of Choice
KDOQI considers it reasonable and ideal to place a PD catheter at least 2 weeks before the anticipated need of the PD treatments. (Expert Opinion)
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KDOQI considers it reasonable for an urgent PD catheter to be placed for immediate PD as necessary under the direction and care of experienced personnel in conducive environments.
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Vessel Preservation
KDOQI considers it reasonable to protect all central and peripheral arteries and veins from damage whenever possible, including the avoidance of peripherally inserted catheters and unnecessary venipunctures, for patients on dialysis or with CKD where dialysis access is expected in the future (CKD G3-G5). (Expert Opinion)
  • Note: Other scenarios where vessel (artery or vein) damage may occur that should be avoided include (1) radial artery access for coronary interventions and (2) venous cardiovascular implantable electronic devices; alternatives such as epicardial/leadless pacing should be considered whenever possible.
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Multidisciplinary Team Approach
KDOQI considers it reasonable to educate on, coordinate, and manage all aspects of dialysis access using a multidisciplinary team within the resource capacities and feasibilities of each facility. (Expert Opinion)
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There is inadequate evidence for KDOQI to make a recommendation on the use of a multidisciplinary team to reduce the rate of CVC use or increase the use of AVF. (, Insufficient)
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Patient and Vessel Examinations: Prepratory Considerations

Patient Clinical Examination

KDOQI recommends that a physical examination focused on vascular anatomy be the basis for the initial assessment and planning of vascular access creation. (Conditional (weak)  “We suggest”, Very low)
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KDOQI considers it reasonable to have greater emphasis on and more training in preoperative clinical examination to assess patients and their vessels to determine the type and location of their vascular access. (Expert Opinion)
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Vessel Mapping for Vascular Access

KDOQI suggests selective preoperative ultrasound in patients at high risk of AV access failure rather than routine vascular mapping in all patients. (Conditional (weak)  “We suggest”, Low)
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KDOQI considers it reasonable to use various imaging studies as needed to evaluate the suitability of vessels for AV access creation, such as ultrasonography for peripheral vessels (including intraoperative ultrasound) and venography for suspected central vein occlusion, while considering the patient’s clinical circumstances and residual kidney function. (Expert Opinion)
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Optimal Vessel Size for Artery and Vein of AV Access Creation

KDOQI considers it reasonable that while there is no minimum-diameter threshold to create an AVF, arteries and veins of <2 mm in diameter should undergo careful evaluation for feasibility and quality to create a functioning AVF. (Expert Opinion)
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KDOQI considers it reasonable to evaluate multiple characteristics of vessel quality for AVF creation (size, distensibility, flow, etc). (Expert Opinion)
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AV Access Creation

Pre-Creation Infection Prevention

KDOQI considers it reasonable to conduct a careful history and physical exam by the operator and managing team prior to AV access creation to identify infection risks that should first be managed before proceeding with AV access creation (eg, dental infection, osteomyelitis, etc). (Expert Opinion)
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KDOQI suggests that the choice of anesthesia for AVF creation should be based on the operator’s discretion and best clinical judgment, as current evidence shows no difference between regional block or local anesthesia in terms of AVF usability, patency, interventions, or patient experience. (Conditional (weak)  “We suggest”, )
(Low-Moderate Level of Evidence)
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AV Access Anastomotic Configuration and Apposition Methods

KDOQI considers it reasonable that the choice of anastomotic configuration and apposition method (eg, vascular clips, sutures) for AVF creation be based on the operator’s discretion and best clinical judgment, as there is insufficient evidence to prefer one configuration or apposition method over another. (Expert Opinion, )
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AV Access Anastomotic Suture Technique

KDOQI considers it reasonable that the choice of suture technique for AV access creation should be based on the operator’s discretion and best clinical judgment, as there is insufficient evidence that any anastomotic suture technique is advantageous in terms of AV access patency or complications. (Expert Opinion)
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Use of Operator-Assisted Maneuvers for AV Access Maturation

KDOQI does not suggest the use of allogenic endothelial implants to improve AVF maturation, patency, or clinical usability or to improve AVG graft patency or reduce thrombosis. (Conditional (weak)  “We suggest”, Very low)
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KDOQI does not suggest the use of pancreatic elastase to improve the patency and clinical use of AVF or AVG. (Conditional (weak)  “We suggest”, Moderate)
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KDOQI considers it reasonable to have a careful individualized approach to operator-enhanced (surgical or endovascular) maneuvers during AV access creation to facilitate AV access maturation, based on the operator’s best clinical judgment and expertise.
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CVC Insertion

Techniques and Other Considerations for Placement

KDOQI recommends the use of image-guided CVC insertions to improve success of insertions. (Conditional (weak) “We suggest”, Moderate)
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KDOQI considers it reasonable that if fluoroscopy is not used to insert a tunnelled CVC, alternative imaging is used to ensure that the CVC tip has been correctly placed.
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Post–AV Access Creation/CVC Insertion Considerations

AV Access Early Postoperative Considerations (0-30 Days)—Early AV Access Complications

KDOQI considers it reasonable for AV access (AVF and AVG) to be evaluated by a surgeon/operator for postoperative complications within 2 weeks and for an appropriate member of the vascular access team to evaluate for AVF maturation by 4-6 weeks after AV access creation and refer for further investigation if not maturing as expected. (Expert Opinion)
Note: Ideally, the surgeon/operator evaluating for complications would be the same individual who created the AV access.
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Postoperative AV Access Maturation

Patient Enhanced
There is inadequate evidence for KDOQI to make a recommendation on the use of upper extremity exercise to facilitate postoperative AVF maturation. (, Insufficient)
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KDOQI recommends the use of whole arm rather than finger exercise, if exercise is used to facilitate AVF maturation. (Conditional (weak)  “We suggest”)
(Moderate-High Quality of Evidence)
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Pharmacologic Intervention
KDOQI does not suggest the use of heparin as an adjuvant therapy in the perioperative period to improve primary patency or initial use of AV access (AVF or AVG). (Conditional (weak)  “We suggest”, Low)
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KDOQI does not suggest the use of adjuvant clopidogrel monotherapy initiation in the perioperative period to improve AVF maturation and reduce the likelihood of primary failure. (Conditional (weak)  “We suggest”, Low)
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KDOQI does not suggest the use of glyceryl-trinitrate to enhance AVF maturation. (Conditional (weak)  “We suggest”, Low)
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KDOQI does not suggest the use of cholecalciferol to enhance AVF maturation. (Conditional (weak)  “We suggest”, Moderate)
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There is inadequate evidence for KDOQI to make a recommendation on the use of clopidogrel-prostacyclin (iloprost) for AVF usability or patency.

(, Insufficient)
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Endovascular and Surgical Intervention
There is inadequate evidence for KDOQI to make a recommendation on the preferred use of surgical or endovascular techniques for postoperative maturation. It is reasonable to consider a careful individualized approach to using either surgical techniques or endovascular techniques when needing to intervene on an AV access to enhance maturation postoperatively. (, Insufficient)
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Timing of CVC Removal

Noncuffed, Nontunneled Catheters (NT-CVC)
KDOQI considers it reasonable to limit the use of temporary, noncuffed, nontunneled dialysis catheters to a maximum of 2 weeks due to increased risk of infection, and this should be considered only in patients in need of emergent access.
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Cuffed, Tunneled CVC
KDOQI considers it reasonable that in HD patients for whom a cuffed, tunneled CVC is the most appropriate permanent dialysis access, there is no maximum time limit to CVC use, but regular evaluation is required to determine if the CVC remains the most appropriate dialysis access. (Expert Opinion)
Note: Appropriate uses of a cuffed, tunneled CVC for chronic hemodialysis include the following:
(1) All other AV access options have been exhausted (after thorough multidisciplinary evaluation)
(2) Temporary switch from another modality (eg, PD, due to PD-related complications such as pleural leak, transplant–acute rejection, etc), but the patient is expected to return to that modality after the complication is adequately resolved
(3) Awaiting live-donor kidney transplant with established surgical date (<90 days)
(4) Very limited life expectancy (eg, <6-12 months)
(5) Clinical conditions that would worsen with AV access s (eg, HF with EF <15%, nontreatable skin lesions where cannulation/ scratching significantly increases infection or rupture risk, etc.).
(6) Patient choice after proper informed consent (eg, HF with EF 85-year-old elderly woman with high risk of AV access failure, needle phobia, and unknown life expectancy)
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Vascular Access Use

Vascular Access General Monitoring

KDOQI considers it reasonable to assess or check the vascular access and surrounding area by physical exam prior to every cannulation (if AV access) or connection (if CVC) for potential complications.
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KDOQI recommends rope ladder cannulation as the preferred cannulation technique for AVFs. (Conditional (weak)  “We suggest”, Moderate)
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KDOQI considers it reasonable to limit AV access buttonhole cannulation only to special circumstances given the associated increased risks of infection and related adverse consequences. (Expert Opinion)
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KDOQI considers it reasonable to avoid buttonhole cannulation in synthetic PTFE grafts due to potential serious consequences. (Expert Opinion)
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KDOQI suggests that when select buttonhole cannulation is performed, the use of buttonhole cannulation devices to facilitate cannulation should be at the discretion and expertise of the cannulator. (Conditional (weak)  “We suggest”, Low)
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KDOQI considers it reasonable to use skilled cannulators with established high rates of cannulation success to perform initial AV access cannulations on patients to help avoid primary infiltration injury of the AV access.
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KDOQI considers it reasonable to have structured training and supervision of dialysis technicians and nurses before and during their initial cannulation attempts, and regular training updates to maintain cannulation competency. (Expert Opinion)
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KDOQI considers it reasonable to support and educate eligible patients on self-cannulation of their AV access (AVF or AVG). (Expert Opinion)
Note: To be clear, any consideration of buttonhole cannulation refers only to AVF and certain AVG materials. AVG made of PTFE should not be accessed by buttonhole cannulation, due to risks of “one-siteitis” and its serious consequences.
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CVC System Connect and Disconnect Procedure Considerations

KDOQI suggests the use of a catheter care protocol for exit site and hub care to reduce catheter-related bloodstream infections and treatment of catheter dysfunction. (Strong  
“We recommend”, Moderate)
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KDOQI considers it reasonable, in addition to correct hand hygiene/washing, to use aseptic technique and masks for patients and staff performing catheter connection and disconnection procedures. (Expert Opinion)
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KDOQI considers it reasonable to cleanse the catheter hub when connecting and disconnecting the catheter with a chlorhexidine based solution. If chlorhexidine is contraindicated (eg, sensitivity, allergy), povidone-iodine solution (preferably with alcohol) is a reasonable substitute and should be used.
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KDOQI considers it reasonable at the time of catheter dressing change to cleanse the skin surrounding the catheter exit site with a chlorhexidine based solution. If chlorhexidine is contraindicated (eg, sensitivity, allergy), povidone-iodine solution (preferably with alcohol) is a reasonable substitute and should be used. (Expert Opinion)
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There is inadequate evidence for KDOQI to make a recommendation on the specific chlorhexidine formulation to use for infection prophylaxis, and this should be based on the clinician’s best clinical judgment and local practical considerations.
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There is inadequate evidence to demonstrate a difference in catheter-related infections with the use of transparent film dressing compared with nontransparent dressing; thus, the choice of catheter dressing material should be based on the clinician’s discretion that considers the patient’s circumstances and uses best clinical judgment. (, Insufficient)
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KDOQI considers it reasonable to use a topical antiseptic or antibiotic barrier at the catheter exit site in addition to cleansing until the exit site is healed to reduce the risk of catheter-related infection. (Expert Opinion)
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There is inadequate evidence to demonstrate a difference in catheter-related infections between the use of various antiseptic or antibiotic topical exit site barriers; thus, the choice of topical exit site barrier should be based on the clinician’s discretion and best clinical judgment.
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KDOQI considers it reasonable to follow these catheter care practices: (Expert Opinion)
  • The frequency of catheter dressing change should be based on the clinician’s discretion and best clinical judgment, with a minimum of once weekly. 
  • Catheter dressings should be protected against wet and dirty environments, particularly when the exit site is not yet fully healed (eg, avoid swimming and showering).
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AV Access Cannulation Complications

KDOQI considers the following therapeutic interventions for cannulation injury reasonable to follow:
  • Any size infiltration: apply ice for a minimum of 10 minutes and refrain from maximizing the blood pump speed.
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  • If the infiltration is moderate, the needle should be withdrawn and manual pressure held over the infiltration site.
(Expert Opinion, )
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  • If the infiltration is significantly large, in addition to the above, a decision on the necessity for dialysis that day is required—if dialysis is required, a site proximal to the infiltration injury should be cannulated; if this is not possible, reattempt at the area of injury should not proceed until manual pressure and ice is applied for 30 minutes.
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  • If a hematoma develops, close assessment of the site, the AV access, and the adjacent extremity should be made, including measurement of swelling, assessment of the presence of flow in the AV access both proximal and distal to the hematoma, and circulation to the associated extremity.
(Expert Opinion, )
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KDOQI considers it reasonable to use ultrasound to help determine direction of flow and proper needle placement in the AV access of select patients as needed and performed by trained operators, to prevent cannulation complications. (Expert Opinion)
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AV Access Flow Dysfunction—Monitoring/Surveillance

Note: “AV access flow dysfunction” refers to clinically significant abnormalities in AV access (AVF or AVG) flow or patency due to underlying stenosis, thrombosis, or related pathology. This is in distinction to other types of AV access complications.

Appropriate Use of Monitoring/Surveillance for AV Access Flow Dysfunction

Physical Examination (Monitoring)
KDOQI recommends regular physical examination or check of the AVF, by a knowledgeable and experienced health practitioner, to detect clinical indicators of flow dysfunction of the AVF.
(Conditional/Strong Recommendation)
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KDOQI considers it reasonable for nephrology trainees and health practitioners involved with clinical HD patient care to be properly trained in physical examination of the AV access to monitor for and detect AV access flow dysfunction. (Expert Opinion)
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Surveillance to Facilitate Patency

There is inadequate evidence for KDOQI to make a recommendation on routine AVF surveillance by measuring access blood flow, pressure monitoring, or imaging for stenosis, that is additional to routine clinical monitoring, to improve access patency. (, Insufficient)
Note: In other words, monitoring of vascular access is primary, while surveillance findings are supplementary, and action should not be based solely on surveillance findings.
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KDOQI does not suggest routine AVG surveillance by measuring access blood flow, pressure monitoring, or imaging for stenosis, that is additional to regular clinical monitoring, to improve AVG patency. (Conditional (weak)  “We suggest”, Low)
Note: In other words, monitoring of vascular access is primary, while surveillance findings are supplementary, and action should not be based solely on surveillance findings.
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Investigation of Abnormalities Detected by Clinical Monitoring

Surveillance and Pre-emptive Intervention for AV Access Stenosis Not Associated With Clinical Indicators
Endovascular Intervention to Improve Patency
KDOQI does not recommend pre-emptive angioplasty of AVFs with stenosis, not associated with clinical indicators, to improve access patency. (Conditional (weak)  “We suggest”, Moderate)
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Surgical Intervention to Improve Patency
There is inadequate evidence for KDOQI to make a recommendation on pre-emptive surgical interventions in AVFs with stenosis, not associated with clinical indicators, to improve access patency. (, Insufficient)
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Pre-emptive Intervention for AV Access Stenosis Associated With Clinical Indicators

KDOQI considers it reasonable for patients with consistently persistent clinical indicators and underlying AV access stenosis to undergo pre-emptive angioplasty of their AV access to reduce the risk of thrombosis and AV access loss. (Expert Opinion)
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AV Access Flow Dysfunction—Prevention

Noninvasive Primary and Secondary Prevention of AV Access Flow Dysfunction

Note: “AV access flow dysfunction” refers to clinically significant abnormalities in AV access (AVF or AVG) flow or patency due to underlying stenosis, thrombosis, or related pathology. This is in distinction to other types of AV access complications.
Fistulas
KDOQI suggests that the use of adjuvant far-infrared therapy to improve AVF primary patency be based on individual circumstances, feasibility, and the clinician’s best judgment and expertise. (Conditional (weak)  “We suggest”, Moderate)
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KDOQI does not suggest the routine use of fish oil or aspirin to prevent AVF flow dysfunction. (Conditional (weak)  “We suggest”)
(Low-Moderate Quality of Evidence)
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There is inadequate evidence for KDOQI to make a recommendation on the use of simvastatin and ezetimibe to reduce AVF interventions or thrombosis.
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There is inadequate evidence for KDOQI to make a recommendation on the use of clopidogrel-prostacyclin to improve AVF primary failure. (, Insufficient)
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Grafts
KDOQI suggests careful consideration of potential individual patient benefits, risks, and circumstances prior to the use of combination dipyridamole (200 mg) and aspirin (25 mg) twice daily to improve AVG primary unassisted patency. (Conditional (weak)  “We suggest”, High)
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KDOQI suggests the use of oral fish oil supplementation, in patients with newly created AV grafts, to reduce patient morbidity (ie, reduce frequency of thrombosis and related corrective interventions). (Conditional (weak)  “We suggest”, Moderate)
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There is inadequate evidence for KDOQI to make a recommendation on the use of oral fish oil supplementation to prolong AVG cumulative patency. (, Insufficient)
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There is inadequate evidence for KDOQI to make a recommendation on the use of simvastatin and ezetimibe for reducing AVG interventions and thrombosis. (, Insufficient)
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AV Access Flow Dysfunction—Confirmation and Treatment

Radiographic Confirmation of Clinically Significant AV Access Lesion

KDOQI considers it reasonable that when clinical monitoring suspects clinically significant AV access lesion (eg, stenosis), further timely and confirmatory evaluation should proceed, including imaging of the dialysis access circuit. (Expert Opinion)
Notes: 
  • A clinically significant lesion is one that contributes to clinical signs and symptoms without other cause (with or without a change in surveillance measurements, such as change in blood flow [Qa] or venous pressures). 
  • Dialysis access circuit is defined as the continuum from the heart and the arterial inflow through the AV access to the venous outflow back to the heart. 
  • The timeframe, choice, and extent of imaging studies for further evaluation are dependent on local resources and the severity of findings on clinical monitoring; a timeframe of less than 2 weeks was deemed reasonable by the KDOQI Work Group.
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KDOQI considers it reasonable to use the smallest volume of iodinated contrast or non-iodinated contrast agents (eg, CO2 gas) by operators knowledgeable in their uses, contraindications, and risks to obtain the best possible image in all patients with CKD to preserve residual kidney function. (Expert Opinion)
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KDOQI considers it reasonable that when further confirmatory imaging studies reveal a culprit lesion responsible for clinical signs and symptoms, the clinically significant lesion is promptly treated. (Expert Opinion)
Note: A clinically significant lesion is one that contributes to clinical signs and symptoms without other cause (with or without a change in surveillance measurements, such as change in blood flow [Qa] or venous pressures).
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General Treatment of Clinically Significant Stenosis or Thrombosed AV Access

KDOQI considers it reasonable to use a careful individualized approach to the treatment of failing or thrombosed AVF and AVG (surgical or endovascular), based on the operator’s best clinical judgment and expertise and considering the patient’s ESKD Life-Plan. (Expert Opinion)
Note: Consider both the patient’s individual circumstances and the operator’s clinical experience and expertise (ie, reasonable capabilities and limitations); preferably discussed and agreed on by the team managing the patient’s vascular access, including but not limited to the patient and one or more of the following: nephrologist, interventionalist, surgeon, vascular access coordinator, cannulators (nurse or technician).
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Treatment of Clinically Significant AV Access Stenosis

Angioplasty
KDOQI considers it reasonable to use balloon angioplasty (with high pressure as needed) as primary treatment of AVF and AVG stenotic lesions that are both clinically and angiographically significant.
Note: Angiographically present stenosis without accompanying clinical signs and symptoms is inadequate to treat/intervene upon.
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There is inadequate evidence for KDOQI to make a recommendation regarding the use of specialized balloons (drugcoated or cutting) versus standard high-pressure balloons in the primary treatment of AVF and AVG stenosis.
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There is inadequate evidence for KDOQI to make a recommendation regarding the optimal duration of balloon inflation time during angioplasty to improve intervention primary patency in the treatment of AVF or AVG stenosis. (, Insufficient)
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KDOQI considers it reasonable that a careful patient-individualized approach to the choice of balloon type for angioplasty of clinically significant AVF and AVG stenosis be based on the operator’s best clinical judgment and expertise.
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Stents
KDOQI suggests the appropriate use of self-expanding stent-grafts in preference to angioplasty alone to treat clinically significant graft-vein anastomotic stenosis in AVG when the goal is overall better 6-month postintervention outcomes after carefully considering the patient’s ESKD Life-Plan. (Conditional (weak)  “We suggest”, Moderate)
Note: Appropriate use avoids cannulation segments. Note: Overall better 6-month outcomes refer to reduced recurrent AVG restenosis ± improved patency.
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KDOQI considers it reasonable to first consider the consequences of placement of a stent-graft on future AV access options according to the patient’s ESKD Life-Plan, with consultation with the vascular access team if necessary, prior to its placement.
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KDOQI suggests that the use of an appropriately placed stent-graft is preferred to angioplasty alone for the treatment of in-stent restenosis in AVG and AVF for overall better 6-month postintervention outcomes. (Conditional (weak)  “We suggest”, Moderate)
Note: Appropriate use avoids cannulation segments.
Note: Overall better 6-month outcomes refer to reduced recurrent AVG and AVF restenosis ± improved patency.
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KDOQI considers it reasonable to avoid the use of bare metal stents for the treatment of clinically and/or angiographically significant AVG and AVF stenotic lesions. (Expert Opinion)
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Treatment of Thrombosed AV Access
KDOQI considers it reasonable that management of each episode of AV access thrombosis is at the operator’s/clinician’s best judgement and discretion, and involves the consideration of the patient’s dialysis access Succession Plan that is consistent with the ESKD Life-Plan, given the compromised AV access patency after either endovascular or surgical treatment.
Note: Operator’s/clinician’s discretion carefully considers both the patient’s individual circumstances and the operator’s/clinician’s own clinical experience and expertise (ie, reasonable capabilities and limitations).
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KDOQI considers it reasonable to surgically treat a failing AV access in the following circumstances: (1) endovascular treatment failures, (2) clinically significant lesions not amenable to endovascular treatment, and (3) situations in which the surgical outcomes are deemed markedly better. (Expert Opinion)
Note: Situations when surgical outcomes are anticipated to be better than alternative options should be first discussed and agreed upon by the team managing the patient’s vascular access, including but not limited to the patient and one or more of the following: nephrologist, interventionalist, surgeon, vascular access coordinator, and cannulation expert, if possible.
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AV Access Infections

Monitoring and Prevention

KDOQI considers it reasonable to educate the patient on washing the access arm using antiseptic to clean the skin prior to every cannulation. (Expert Opinion)
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KDOQI considers it reasonable to check the vascular access and surrounding area prior to every cannulation for signs and symptoms of infection. (Expert Opinion)
Note: This check should be done by patient and cannulator (if patient does not self-cannulate).
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Diagnosis

KDOQI considers it reasonable to use radiologic imaging to help confirm the diagnosis of AV access infection; however, physical examination remains the hallmark for assessing for infection.
Note: Radiologic imaging includes duplex ultrasound, ± CT scan, PET, and nuclear medicine scans (eg, indium scan). Note: Signs of infection include erythema, skin breakdown, purulent discharge, and presence of exposed graft.
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KDOQI considers it reasonable to investigate and closely monitor for metastatic complications (eg, endocarditis, spinal abscesses, septic arthritis) in patients with buttonhole infection from particularly dangerous organisms such as S. aureus, Gram-negative bacteria, and fungal organisms. (Expert Opinion)
Note: Investigations include 2D echocardiography, MRI, joint aspirate, and other, as appropriate.
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Treatment

KDOQI considers it reasonable to obtain cultures and sensitivities of the blood and any available infected AV access vessel/material, surrounding tissue, or drainage prior to initiating antibiotic therapy. (Expert Opinion)
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KDOQI considers it reasonable for infected AV access the rapid initiation of empiric broad-spectrum antibiotics and timely referral to a surgeon knowledgeable in the management of vascular access complications. (Expert Opinion)
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KDOQI considers it reasonable to have strict follow-up of culture results with the appropriate change in antibiotics based on organism sensitivities, with antibiotic duration according to extent of vascular access infection and surgical intervention. (Expert Opinion)
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KDOQI considers it reasonable that the specific surgical treatment for AV access infections (with concurrent antibiotics) should be based on the patient’s individual circumstances considering the extent of infection, offending organism, and future vascular access options.
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AV Access Aneurysms

Recognition and Diagnosis
KDOQI considers it reasonable to check AV access for aneurysm/pseudoaneurysms at each dialysis session by knowledgeable care providers, including but not limited to dialysis technicians, nurses, nephrologists, and vascular access coordinator. (Expert Opinion)
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KDOQI considers it is reasonable to proactively educate patients on emergency procedures for aneurysm rupture and to obtain proactive surgical assessment when clinical findings suggest an AV access aneurysm/pseudoaneurysm to be at risk of complications.
Note: An aneurysm/pseudoaneurysm that is considered at risk of complications is one with evidence of associated symptoms or skin breakdown.
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KDOQI considers it is reasonable to obtain emergent surgical assessment and treatment for AV access aneurysm/pseudoaneurysm complications such as erosion or hemorrhage. (Expert Opinion)
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KDOQI considers it reasonable to use duplex ultrasound to corroborate the physical examination suggesting an AV access aneurysm/pseudoaneurysm and to obtain information on the size, presence of stenosis/thrombus, and impact on the AV access (including flow rate [Qa] and status of the arterial inflow and the venous outflow). (Expert Opinion)
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Management
KDOQI considers it reasonable that the presence of an aneurysm/pseudoaneurysm alone in the absence of symptoms (ie, asymptomatic) is not an indication for definitive treatment. (Expert Opinion)
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KDOQI considers it reasonable to avoid cannulating the access segment(s) that involve the aneurysm/pseudoaneurysm if there are alternative sites. In the rare scenario where there are absolutely no suitable alternative cannulation sites, the sides (base) of the aneurysm/pseudoaneurysm should be cannulated (ie, avoid the top). (Expert Opinion)
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KDOQI considers it reasonable to obtain appropriate imaging of the arterial inflow and venous outflow to assess volume flow or stenotic problems that may need correction prior to or during definitive treatment of symptomatic aneurysm/ pseudoaneurysm. (Expert Opinion)
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KDOQI considers it reasonable that surgical management is the preferred treatment for patients with symptomatic, large, or rapidly expanding AV access aneurysm/pseudoaneurysm (see “Treatment–Definitive” below). (Expert Opinion)
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KDOQI considers it reasonable that a definitive surgical treatment is usually required for anastomotic aneurysms/pseudoaneurysms. (Expert Opinion)
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Treatment–Definitive
KDOQI considers it reasonable that open surgical treatment should be deemed the definitive treatment for AV access aneurysms/pseudoaneurysms with the specific approach determined based on the local expertise. (Expert Opinion)
Note: This approach may include a plan for staged repair of multiple aneurysms to avoid bridging CVCs in the perioperative period.
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KDOQI considers it reasonable to use covered intraluminal stents (stent grafts) as an alternative to open surgical repair of AV access aneurysms/pseudoaneurysms, only in special circumstances such as specific patient contraindication to surgery or lack of surgical option, due to the associated risk of infection in this scenario. (Expert Opinion)
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KDOQI considers it reasonable that, should a stent graft be used to treat AV access aneurysms/pseudoaneurysm, cannulation over the stent graft segment be avoided when possible. (Expert Opinion)
Note: The use of stent grafts to manage aneurysms/pseudoaneurysms is not an FDA-approved indication.
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Prevention
KDOQI considers it reasonable that appropriate cannulation techniques should be implemented to reduce the occurrence of AV access aneurysms/pseudoaneurysms. (Expert Opinion)
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AV Access Steal

KDOQI considers it reasonable that strategies to both prevent and treat AV access steal should be developed and implemented before AV access creation, to reduce the risk of AV access steal and related morbidity, respectively.
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KDOQI considers it reasonable that post AV access creation, patients should be monitored closely for signs and symptoms associated with AV access steal and managed appropriately with consideration of individual circumstances as follows): 
  • Mild to moderate signs and symptoms require close monitoring for progression of ischemia and worsening of signs and symptoms 
  • Moderate to severe signs and symptoms often require urgent treatment to correct the hemodynamic changes and prevent any longer-term disability
(Expert Opinion)
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KDOQI considers it reasonable that patients with signs and symptoms consistent with AV access steal should be referred urgently to a surgeon/interventionist familiar with the diagnosis and options for the definitive treatment of AV access complications, particularly AV access steal. (Expert Opinion)
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KDOQI considers it reasonable that the optimal treatment of AV access steal should be determined based on the patient’s clinical presentation, local expertise, and resources. (Expert Opinion)
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Other AV Access Complications

Management of AVG Seroma
KDOQI considers it reasonable to carefully monitor for complications of AVG seroma and manage based on the patient’s individual circumstances and the clinician’s best judgment and discretion. (Expert Opinion)

Note: Operator’s/clinician’s discretion carefully considers both the patient’s individual circumstances and the operator’s/clinician’s own clinical experience and expertise (ie, reasonable capabilities and limitations).

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Management of High-Flow AV Access
KDOQI considers it reasonable to closely monitor and prophylactically manage AV access with high flows to avoid serious or irreversible complications (eg, high output cardiac failure), based on the patient’s individual circumstances and the clinician’s best judgment and discretion.
Note: Operator’s/clinician’s discretion carefully considers both the patient’s individual circumstances and the operatot’s/clinician’s own clinical experience and expertise (ie, reasonable capabilities and limitations).
Note: Close monitoring refers to physical examination and history on routine dialysis rounds and determination of Qa/CO every 6-12 months, or more frequently as needed.
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Treatment and Prevention of CVC Complications

Monitoring/Surveillance of CVC Complications
KDOQI considers it reasonable to perform a basic medical history focused on signs and symptoms of CVC-related complications (eg, dysfunction, infection) and physical examination or check of the dialysis catheter, exit site, tunnel, and surrounding area at each catheter dressing change or dialysis session.
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Catheter Dysfunction

Definition of CVC Dysfunction
KDOQI considers it reasonable to assess for CVC dysfunction during each HD session using the following updated definition of CVC dysfunction: failure to maintain the prescribed extracorporeal blood flow required for adequate hemodialysis without lengthening the prescribed HD treatment.
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Pharmacologic Prevention of CVC Dysfunction
CVC Connectors to Prevent CVC Dysfunction or Bacteremia
KDOQI considers it reasonable to have an individualized approach to use special CVC connectors based on the clinician’s discretion and best clinical judgment.
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KDOQI considers it reasonable to use an antimicrobial barrier cap to help reduce CRBSI in high-risk patients or facilities; the choice of connector should be based on clinician’s discretion and best clinical judgment. (Expert Opinion)
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Intraluminal Agents to Prevent CVC Dysfunction
KDOQI considers it reasonable that the choice to use citrate or heparin as a CVC locking solution be based on the clinician’s discretion and best clinical judgment, as there is inadequate evidence to demonstrate a difference in CVC survival or complications between these locking solutions.
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KDOQI suggests the use of low-concentration citrate (<5%) CVC locking solution, if feasible, to help prevent CRBSI and CVC dysfunction. (Conditional (weak)  “We suggest”, Low)
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KDOQI suggests that TPA may be prophylactically used as a CVC locking solution once per week to help reduce CVC dysfunction. (Conditional (weak)  “We suggest”, Low)
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There is inadequate evidence for KDOQI to make a recommendation on the comparative use of the following CVC locking agents for CVC dysfunction or infection prophylaxis: tinzaparin versus unfractionated heparin, taurolidine/citrate versus heparin with or without gentamicin, neutral valve connector (Tego [ICU Medical]) versus citrate (46.7%) locking solution. (, Insufficient)
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Systemic Agents to Prevent CVC Dysfunction
KDOQI recommends against the routine use of prophylactic systemic anticoagulants (eg, warfarin) for the sole purpose of maintaining or improving CVC patency, as there is inadequate evidence of benefit for CVC patency but suggestion of increased risk of harm. (Conditional (weak)  “We suggest”, Low)
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KDOQI suggests that low-dose aspirin may be used to maintain tunneled CVC patency in patients with low bleeding risk. (Conditional (weak)  “We suggest”, Low)
Note: CVC refers to tunneled hemodialysis CVCs unless otherwise specified.
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Treatment and Management of CVC Dysfunction

Medical Management of CVC Dysfunction
Conservative Maneuvers
KDOQI considers it reasonable for a conservative bedside approach to managing CVC dysfunction prior to other medical or mechanical interventions.
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Pharmacologic Maneuvers
KDOQI recommends intraluminal administration of a thrombolytic agent in each CVC port to restore function of dysfunctional CVCs due to thrombosis. (Conditional (weak)  “We suggest”, Moderate)
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KDOQI recommends the use of alteplase or urokinase plus citrate 4% per limb for restoring intraluminal CVC blood flow in an occluded CVC. (Conditional (weak)  “We suggest”, Moderate)
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KDOQI suggests intraluminal administration of alteplase 2 mg in preference to alteplase 1 mg in each CVC port to restore function of dysfunctional CVCs due to thrombosis. (Conditional (weak)  “We suggest”, Moderate)
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KDOQI suggests administering alteplase by the dwell or push method to treat CVC dysfunction. (Conditional (weak)  “We suggest”, Low)
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Mechanical Management of CVC Dysfunction
KDOQI considers it reasonable that the decision to perform fibrin sheath disruption during CVC exchange for CVC dysfunction be based on the operator’s discretion and best clinical judgment.
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There is inadequate evidence for KDOQI to make a recommendation on the efficacy of or method of fibrin sheath disruption based on CVC patency outcomes.
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KDOQI considers it reasonable that CVC removal followed by replacement at a different site should be the last resort after conservative, medical, and other mechanical (eg, angioplasty, CVC exchange) strategies have all failed to treat CVC dysfunction. (Expert Opinion)
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Catheter-Related Infection

Definitions of Catheter-Related Infections
KDOQI considers it reasonable to consistently use standardized definitions for CVC-related infections to allow for comparisons across programs/jurisdictions. (Expert Opinion)
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KDOQI considers it reasonable to use the KDOQI VA-2019 definitions of CVC-related infections, which consider the unique circumstances of a hemodialysis patient. (Expert Opinion)
Note: In order to harmonize definitions, the KDOQI VA-2019 definitions encompass those of other organizations.
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Prevention of CVC-Related Infection

General Prevention of CVC Infection and Use of Infection Surveillance Programs and Infection Control Teams
KDOQ considers it reasonable for an infection control program to include an infection surveillance team to monitor, track (in an electronic database), help prevent, and evaluate outcomes of vascular access infections and, in particular, CVCrelated infections.
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Specific Prevention of CVC Infection
Surveillance of CVC Colonization and Preemptive CRBSI Management
There is inadequate evidence for KDOQI to support routine CVC surveillance cultures for colonization and subsequent preemptive antibiotic lock installation if culture is positive. (, Insufficient)
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Methods to Prevent CRBSI
Extraluminal Strategies
See “CVC System Connect and Disconnect Procedure Considerations” and section on “Prevention of CVC Dysfunction.”
Intraluminal Strategies
KDOQI suggests that the selective use of specific prophylactic antibiotic locks can be considered in patients in need of long-term CVC who are at high risk of CRSBI (eg, multiple prior CRSBI), especially in facilities with high rates of CRBSI (eg, >3.5/1,000 days). (Conditional (weak)  “We suggest”)
(Low-Moderate Level of Evidence)
Note: Under these circumstances and given the current data, KDOQI considers it reasonable for prophylactic use of specific antibiotics: cefotaxime, gentamicin, or cotrimoxazole (TMP-SMX). KDOQI cannot support the routine prophylactic use of antibiotic locks with very low supporting evidence.
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KDOQI suggests that the selective use of specific prophylactic antimicrobial locks can be considered in patients in need of long-term CVC who are at high risk of CRSBI, especially in facilities with high rates of CRBSI (eg, >3.5/1,000 days).
(Low-Moderate Quality of Evidence)
Note: Under these circumstances and given the current data, KDOQI can support the prophylactic use of methylene blue. KDOQI cannot support the routine prophylactic use of antimicrobial locks with very low supporting evidence.
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KDOQI suggests that the selective use of once weekly prophylactic CVC locking with thrombolytic agent (recombinant TPA) can be considered in patients in need of long-term CVC who are at high risk of CRSBI, especially in facilities with high rates of CRBSI (eg, >3.5/1,000 days). (Conditional (weak)  “We suggest”, Moderate)
Note: Under these circumstances and given the current data, KDOQI can support the prophylactic use of recombinant TPA. Note: High-risk patients refers to those with prior multiple CRSBI, S. aureus nasal carriers.
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Treatment of CVC-Related Infection

Management of the Patient With a CVC-Related Infection
KDOQI considers it reasonable and necessary to obtain appropriate cultures prior to initiating empiric antibiotics for the treatment of suspected CVC-related infection, with a change in antibiotics according to culture sensitivities.
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Management of the CVC in a Patient With a CVC-Related Infection
KDOQI considers it reasonable to have an individualized approach to the management of an infected catheter based on the patient’s health, dialysis, and vascular access circumstances and should follow the detailed guidance. Options include CVC exchange via guidewire, CVC removal and reinsertion, CVC salvage, and concurrent antibiotic lock (particularly if the CVC is deemed to be the patient’s final access). (Expert Opinion)
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Other Vascular Access-Related Complications

Treatment and Intervention of Asymptomatic Central Venous Stenosis Without Clinical Indicators
KDOQI considers it reasonable that if asymptomatic central venous stenosis (without clinical indicators) is identified and/ or associated with the prior or current presence of a CVC, it should not be treated. (Expert Opinion)
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Investigation and Treatment of Symptomatic Central Venous Stenosis With Clinical Indicators
Same as guidelines for “AV Access Flow Dysfunction–Confirmation And Treatment” (, )
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Management of CVC Fibrin Sheath Associated With Clinical Problems
KDOQI considers it reasonable that when a CVC fibrin sheath is associated with adverse clinical manifestations (CVC dysfunction and/or infection), a CVC exchange with or without balloon disruption of the fibrin sheath should be performed. (Expert Opinion)
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Recommendation Grading

Overview

Title

Vascular Access

Authoring Organization

National Kidney Foundation

Publication Month/Year

March 1, 2020

Last Updated Month/Year

February 5, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

It provides evidence-based guidelines for hemodialysis vascular access

Target Patient Population

Patients with hemodialysis

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management

Diseases/Conditions (MeSH)

D062666 - Vascular Access Devices, D006437 - Hemodialysis, Home, D058017 - Vascular Grafting, D016157 - Vascular Fistula, D014656 - Vascular Surgical Procedures

Keywords

vascular access

Source Citation

Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP; National Kidney Foundation. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020 Apr;75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001. Epub 2020 Mar 12. Erratum in: Am J Kidney Dis. 2021 Apr;77(4):551. PMID: 32778223.

Supplemental Methodology Resources

Data Supplement, Evidence Tables

Methodology

Number of Source Documents
667
Literature Search Start Date
January 1, 2020
Literature Search End Date
October 31, 2020
Description of External Review Process
This guideline and supplementary files were put through formal internal and external review processes. Internal review took place in March 2019 and included feedback from 14 individuals and groups, including the NKF Scientific Advisory Board, American Society of Diagnostic and Interventional Nephrology, and Vascular Access Society of the Americas. Reviewers were asked to read each recommendation and its supporting text; indicate whether they agreed, disagreed, or partially agreed with each; and provide comment if desired.
Description of Public Comment Process
A public review period (May 2019) followed the same format and received 50 responses. A link to all documents was emailed to individuals who registered to receive it, and NKF publicized the review through email and social media channels. Changes and edits were made to the manuscript following each review.
Specialties Involved
Nephrology
Description of Systematic Review
See below.
List of Questions
Several important questions arise when considering AV access surveillance to reduce thrombosis and improve AV access patency: (1) What is the diagnostic value of surveillance for detection of stenosis? (2) What are the validated diagnostic thresholds by surveillance indicators (eg, Qa, change in Qa/time) that accurately diagnose stenosis that will lead to future thrombosis? (3) What factors, other than stenosis, contribute to abnormal surveillance indicators? (4) What is the appropriate intervention when stenosis is detected by surveillance in the absence of clinical indicators? and (5) What is the AV access patency outcome after intervention of stenosis not associated with a clinical indicator, and does this differ from intervention of stenosis detected by clinical examination?
Description of Study Criteria
Refer to the Supplemental: Literature Search Strategy. Reasons for Exclusion: Case Study, Abstract, Brief Report, Commentary/Editorial, More Recent Available, More Recent Review Available, Not English, Original Research Included, Wrong Intervention, Wrong Population, Wrong Condition/Disorder, Wrong Outcome, Wrong Timing, Wrong Setting.
Description of Search Strategy
The ERT searched bibliographic databases, including MEDLINE and Embase via Ovid, and the Cochrane Library to identify studies published from January 2000 through October 2016. Search strategies are available in Supplement 1. They supplemented bibliographic database searches with citation searching of identified studies.
Description of Study Selection
The ERT included trials and prospective observational studies with parallel groups that compared vascular access interventions and reported outcomes preselected for their review. Relevant interventions included those related to different vascular access types. They excluded studies enrolling predominately (<75%) pediatric or acute kidney injury participants, studies enrolling predominately (<75%) participants with vascular accesses created before 2000, studies not reporting outcomes relevant to their review, and studies not published in English. Two investigators independently reviewed titles and abstracts of search results to identify potentially eligible references. Two investigators independently screened the full text of those references to determine if they met inclusion criteria. A third investigator resolved discrepancies.
Description of Evidence Analysis Methods
The Work Group drafted clinical practice guideline statements based on the evidence amassed by the ERT. Some statements are similar to those of the previous guidelines published in 200613 but have been re-emphasized or reinterpreted in light of new data. For each of the guideline statements, the quality of the evidence and the strength of the recommendations were graded separately using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach criteria.9,14 The Work Group used an adapted version of these scales using high to very low for quality of the evidence and strong or conditional for the strength of the recommendation. Recommendation strength includes assessment of the statement’s potential clinical impact (Tables A and B).
Description of Evidence Grading
A: High quality of evidence. The Work Group is confident that the true effect lies close to that of the estimate of the effect. B: Moderate quality of evidence. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. C: Low quality of evidence. The true effect may be substantially different from the estimate of the effect. D: Very low quality of evidence. The estimate of effect is very uncertain and often will be far from the truth
Description of Recommendation Grading
NKF uses a GRADE Methodology. Level 1. Strong Recommendation: “We Recommend.” Clinicians: most patients should receive the recommended course of action. Level 2 Conditional Recommendation: “We Suggest.” Clinicians: Different choices will be appropriate for different patients. Each patient needs help to arrive at a management decision consistent with her or his values and preferences. Inadequate Evidence: The quality of the evidence was insufficient to make a suggestion or recommendation (to support or not to support the intervention or topic) but important enough to acknowledge as an area for future study. Work Group derived: Ungraded. “KDOQI considers it reasonable”: Ungraded recommendations are based on Work Group consensus and the literature not found through the formal ERT literature review.
Description of Funding Source
NKF provides funding for Guideline Development.
Company/Author Disclosures
All authors provide conflict of interest disclosures per NKF COI policy.
Percentage of Authors Reporting COI
100