Rationale for Guideline for "Preferred Vascular Access"

Preferred vascular access for hemodialysis

Contribution from the KDOQI 2006 Hemodialysis Update workgroup

Source: KDOQI HD Adequacy guidelines for 2006 (National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1):

The order of preference for placement of fistulae in patients with kidney failure who choose HD as their initial mode of KRT should be (in descending order of preference):

• Preferred: Fistulae. (B)
  • A wrist (radiocephalic) primary fistula. (A)
  • An elbow (brachiocephalic) primary fistula. (A)
  • A transposed brachial basilica vein fistula: (B)
• Acceptable: AV Graft of synthetic or biological material, such as: (B)
  • A forearm loop graft, preferable to a straight configuration.
  • Upper-arm graft.
  • Chest wall or “necklace” prosthetic graft or lower extremity fistula or graft; all upper-arm sites should be exhausted.
• Avoid if possible: Long-term catheters.

Rationale: The preference of fistulae over all other forms of access arises from their functional advantages because of a lower rate of complications. Fistulae have the lowest rate of thrombosis (1) and require the fewest interventions, (1,2) providing longer survival of the access. (1-4) The number of access events is 3- to 7-fold greater in prosthetic bridge grafts than in native fistulae. (1,2,4) As a result, costs of implantation and access maintenance are the lowest. (4-6) Fistulae have lower rates of infection than grafts, which, in turn, are less prone to infection than percutaneous catheters and subcutaneous port catheter systems. (7) Vascular access infections in HD patients are common, can be severe, and contribute to infection as the second leading cause of death in patients with CKD stage 5. (8) Fistulae are associated with increased survival and lower hospitalization. Patients receiving catheters (RR = 2.3) and grafts (RR = 1.47) have a greater mortality risk than patients dialyzed with fistulae. (9) Epidemiological evidence also indicates that greater use of fistulae reduces mortality and morbidity. (9-12)

References:

1. Perera GB, Mueller MP, Kubaska SM, Wilson SE, Lawrence PF, Fujitani RM: Superiority of autogenous arteriovenous hemodialysis access: Maintenance of function with fewer secondary interventions. Ann Vasc Surg 18:66- 73, 2004
2. Huber TS, Carter JW, Carter RL, Seeger JM: Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: A systematic review. J Vasc Surg 38:1005-1011, 2003
3. Pisoni RL, Young EW, Dykstra DM, et al: Vascular access use in Europe and the United States: Results from the DOPPS. Kidney Int 61:305-316, 2002
4. Mehta S: Statistical summary of clinical results of vascular access procedures for haemodialysis, in Sommer BG, Henry ML (eds): Vascular Access for Hemodialysis-II (ed 2). Chicago, IL, Gore, 1991, pp 145-157
5. The Cost Effectiveness of Alternative Types of Vascular access and the Economic Cost of ESRD. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1995, pp 139-157
6. Eggers P, Milam R: Trends in vascular access procedures and expenditures in Medicare’s ESRD program, in Henry ML (ed): Vascular Access for Hemodialysis-VII. Chicago, IL, Gore, 2001, pp 133-143
7. Nassar GM, Ayus JC: Infectious complications of the hemodialysis access. Kidney Int 60:1-13, 2001
8. Gulati S, Sahu KM, Avula S, Sharma RK,Ayyagiri A, Pandey CM: Role of vascular access as a risk factor for infections in hemodialysis. Ren Fail 25:967-973, 2003
9. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK: Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 60:1443-1451, 2001
10. Woods JD, Port FK: The impact of vascular access for haemodialysis on patient morbidity and mortality. Nephrol Dial Transplant 12:657-659, 1997
11. Xue JL, Dahl D, Ebben JP, Collins AJ: The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients. Am J Kidney Dis 42:1013-1019, 2003
12. Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG: Vascular access and all-cause mortality: A propensity score analysis. J Am Soc Nephrol 15:477-486, 2004