• Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006 Jul;48 Suppl 1:S248-73. PubMed

2.1.6 In the patient receiving PD who is manifesting signs of modality failure, the decision to create a backup fistula should be individualized by periodically reassessing need. In individuals at high risk for failure (see the National Guideline Clearinghouse [NGC] summary of the PD Adequacy Guidelines), evaluation and construction should follow the procedures in CPG 1 for patients with CKD stage 4.

2.2 Fistulae:

2.2.1 Enhanced maturation of fistulae can be accomplished by selective obliteration of major venous side branches in the absence of a downstream stenosis. [B]

2.3 Dialysis AVGs:

2.3.1 The choice of synthetic or biological material should be based on the surgeon's experience and preference. The choice of synthetic or biological conduits should consider local experience, technical details, and cost. [B]

2.3.2 There is no convincing evidence to support tapered versus uniform tubes, externally supported versus unsupported grafts, thick- versus thin-walled configurations, or elastic versus nonelastic material. [A]

2.3.3 While the majority of past experience with prosthetic grafts has been with the use of polytetrafluoroethylene (PTFE), other prosthetics (e.g., polyurethane [PU]) and biological conduits (bovine) have been used recently with similar outcomes. [B]

2.3.4 Patients with swelling that does not respond to arm elevation or that persists beyond 2 weeks after dialysis AV access placement should receive an imaging study or other noncontrast study to evaluate central venous outflow (see CPG 1). [B]

2.4 Catheters and port catheter systems:

2.4.1 The preferred insertion site for tunneled cuffed venous dialysis catheters or port catheter systems is the right internal jugular vein. Other options include the right external jugular vein, left internal and external jugular veins, subclavian veins, femoral veins, and translumbar and transhepatic access to the inferior vena cava (IVC). Subclavian access should be used only when no other upper-extremity or chest-wall options are available. [A]

2.4.2 Ultrasound should be used in the placement of catheters. [B]

2.4.3 The position of the tip of any central catheter should be verified radiologically. [B]

Guideline 3. Cannulation of Fistulae and Grafts and Accession of Hemodialysis Catheters and Port Catheter Systems

The use of aseptic technique and appropriate cannulation methods, the timing of fistula and graft cannulation, and early evaluation of immature fistulae are all factors that may prevent morbidity and may prolong the survival of permanent dialysis accesses.

3.1 Aseptic techniques:

3.1.1 For all vascular accesses, aseptic technique should be used for all cannulation and catheter accession procedures. (See the following table) [A]

Skin Preparation Technique for Subcutaneous arteriovenous (AV) Access

3.2 Maturation and cannulation of fistulae:

3.2.1 A primary fistula should be mature, ready for cannulation with minimal risk for infiltration, and able to deliver the prescribed blood flow throughout the dialysis procedure. (See the following table.) [B]

Technique for Mature Arteriovenous Fistula (AVF) Cannulation

Definitions: HD, hemodialysis

3.2.2 Fistulae are more likely to be useable when they meet the Rule of 6s characteristics: flow greater than 600 mL/min, diameter at least 0.6 cm, no more than 0.6 cm deep, and discernible margins. [B]

3.2.3 Fistula hand-arm exercise should be performed. [B]

3.2.4 If a fistula fails to mature by 6 weeks, a fistulogram or other imaging study should be obtained to determine the cause of the problem. [B]

3.3 Cannulation of AVGs:

Grafts generally should not be cannulated for at least 2 weeks after placement and not until swelling has subsided so that palpation of the course of the graft can be performed. The composite PU graft should not be cannulated for at least 24 hours after placement and not until swelling has subsided so that palpation of the course of the graft can be performed. Rotation of cannulation sites is needed to avoid pseudoaneurysm formation. (See the following table.) [B]

Technique for AVG Cannulation

Definitions: AVG, arteriovenous graft; HD, hemodialysis

3.4 Dialysis catheters and port catheter systems:

Infection-control measures that should be used for all HD catheters and port catheter systems include the following:

3.4.1 The catheter exit site or port cannulation site should be examined for proper position of the catheter/port catheter system and absence of infection by experienced personnel at each HD session before opening and accessing the catheter/port catheter system. [B]

3.4.2 Changing the catheter exit-site dressing at each HD treatment, using either a transparent dressing or gauze and tape. [A]

3.4.3 Using aseptic technique to prevent contamination of the catheter or port catheter system, including the use of a surgical mask for staff and patient and clean gloves for all catheter or port catheter system connect, disconnect, and dressing procedures. [A]

Access Physical Examination

Definitions: AVG: Arteriovenous graft

Considerations for Accessing Catheters and Cleansing Catheter Exit Sites

^a Check catheter manufacturer's warnings about effect of disinfectants on catheter material.

^b Use according to manufacturer's directions.

Definitions: CVC, central venous catheter

Guideline 4. Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing

Prospective surveillance of fistulae and grafts for hemodynamically significant stenosis, when combined with correction of the anatomic stenosis, may improve patency rates and may decrease the incidence of thrombosis.

The Work Group recommends an organized monitoring/surveillance approach with regular assessment of clinical parameters of the AV access and HD adequacy. Data from the clinical assessment and HD adequacy measurements should be collected and maintained for each patient's access and made available to all staff. The data should be tabulated and tracked within each HD center as part of a Quality Assurance (QA)/Continuous quality improvement (CQI) program.

4.1 Physical examination (monitoring):

Physical examination should be used to detect dysfunction in fistulae and grafts at least monthly by a qualified individual. [B]

4.2 Surveillance of grafts:

Techniques, not mutually exclusive, that may be used in surveillance for stenosis in grafts include:

4.2.1 Preferred:

4.2.1.1 Intra-access flow by using 1 of several methods that are outlined below using sequential measurements with trend analysis. [A]

Flow Methods in Dialysis Access

4.2.1.2 Directly measured or derived static venous dialysis pressure by 1 of several methods. [A] (Protocol provided in the table below for using transducers on HD machines to measure directly; criteria in the table below for derived methods.)

4.2.1.3 Duplex ultrasound. [A]

4.2.2 Acceptable:

4.2.2.1 Physical findings of persistent swelling of the arm, presence of collateral veins, prolonged bleeding after needle withdrawal, or altered characteristics of pulse or thrill in a graft. [B]

4.2.3 Unacceptable:

4.2.3.1 Unstandardized dynamic venous pressures (DVPs) should not be used. [A]

Static Intra-Access Pressure (IAP) Surveillance

Criteria for Intervention

4.3 Surveillance in fistulae:

Techniques, not mutually exclusive, that may be used in surveillance for stenosis in arteriovenous fistulae (AVFs) include:

4.3.1 Preferred:

4.3.1.1 Direct flow measurements. [A]

4.3.1.2 Physical findings of persistent swelling of the arm, presence of collateral veins, prolonged bleeding after needle withdrawal, or altered characteristics of pulse or thrill in the outflow vein. [B]

4.3.1.3 Duplex ultrasound. [A]

4.3.2 Acceptable:

4.3.2.1 Recirculation using a non-urea-based dilutional method. [B]

4.3.2.2 Static pressures [B], direct or derived. [B]

4.4 When to refer for evaluation (diagnosis) and treatment:

4.4.1 One should not respond to a single isolated abnormal value. With all techniques, prospective trend analysis of the test parameter has greater power to detect dysfunction than isolated values alone. [A]

4.4.2 Persistent abnormalities in any of the monitoring or surveillance parameters should prompt referral for access imaging. [A]

4.4.3 An access flow rate less than 600 mL/min in grafts and less than 400 to 500 mL/min in fistulae. [A]

4.4.4 A venous segment static pressure (mean pressures) ratio greater than 0.5 in grafts or fistulae. [A]

4.4.5 An arterial segment static pressure ratio greater than 0.75 in grafts. [A]

Access Flow Protocol Surveillance

Patient Education Basics

Guideline 5. Treatment of Fistula Complications

Appropriate interventions for access dysfunction may result in an increased duration of survival of the AVF.

5.1 Problems developing in the early period after AVF construction (first 6 months) should be promptly addressed.

5.1.1 Persistent swelling of the hand or arm should be expeditiously evaluated and the underlying pathology should be corrected. [B]

5.1.2 A program should be in place to detect early access dysfunction, particularly delays in maturation. The patient should be evaluated no later than 6 weeks after access placement. [B]

Summary of Physical Examination

5.2 Intervention:
Intervention on a fistula should be performed for the presence of:

5.2.1 Inadequate flow to support the prescribed dialysis blood flow. [B]

5.2.2 Hemodynamically significant venous stenosis. [B]

5.2.3 Aneurysm formation in a primary fistula. Postaneurysmal stenosis that drives aneurysm also should be corrected. The aneurysmal segment should not be cannulated. [B]

5.2.4 Ischemia in the access arm. [B]

5.3 Indications for preemptive percutaneous angioplasty (PTA):

A fistula with a greater than 50% stenosis in either the venous outflow or arterial inflow, in conjunction with clinical or physiological abnormalities, should be treated with PTA or surgical revision. [B]

5.3.1 Abnormalities include reduction in flow, increase in static pressures, access recirculation preempting adequate delivery of dialysis, or abnormal physical findings. [B]

5.4 Stenosis, as well as the clinical parameters used to detect it, should return to within acceptable limits following intervention. [B]

5.5 Thrombectomy of a fistula should be attempted as early as possible after thrombosis is detected, but can be successful even after several days. [B]

5.6 Access evaluation for ischemia:

5.6.1 Patients with an AVF should be assessed on a regular basis for possible ischemia. [B]

5.6.2 Patients with new findings of ischemia should be referred to a vascular access surgeon emergently. [B]

5.7 Infection:

Infections of primary AVFs are rare and should be treated as subacute bacterial endocarditis with 6 weeks of antibiotic therapy. Fistula surgical excision should be performed in cases of septic emboli. [B]

Guideline 6. Treatment of Arteriovenous Graft Complications

Appropriate management and treatment of AVG complications may improve the function and longevity of the vascular access.

6.1 Extremity edema:

Patients with extremity edema that persists beyond 2 weeks after graft placement should undergo an imaging study (including dilute iodinated contrast) to evaluate patency of the central veins. The preferred treatment for central vein stenosis is PTA. Stent placement should be considered in the following situations:

6.1.1 Acute elastic recoil of the vein (>50% stenosis) after angioplasty. [B]

6.1.2 The stenosis recurs within a 3-month period. [B]

6.2 Indicators of risk for graft rupture:

Any of the following changes in the integrity of the overlying skin should be evaluated urgently:

6.2.1 Poor eschar formation. [B]

6.2.2 Evidence of spontaneous bleeding. [B]

6.2.3 Rapid expansion in the size of a pseudoaneurysm. [B]

6.2.4 Severe degenerative changes in the graft material. [B]

6.3 Indications for revision/repair:

6.3.1 AVGs with severe degenerative changes or pseudoaneurysm formation should be repaired in the following situations:

6.3.1.1 The number of cannulation sites are limited by the presence of a large (or multiple) pseudoaneurysm(s). [B]

6.3.1.2 The pseudoaneurysm threatens the viability of the overlying skin. [B]

6.3.1.3 The pseudoaneurysm is symptomatic (pain, throbbing). [B]

6.3.1.4 There is evidence of infection. [B]

6.3.2 Cannulation of the access through a pseudoaneurysm must be avoided if at all possible and particularly so if the pseudoaneurysm is increasing in size. [B]

6.4 Treatment of stenosis without thrombosis:
Stenoses that are associated with AVGs should be treated with angioplasty or surgical revision if the lesion causes a greater than 50% decrease in the luminal diameter and is associated with the following clinical/physiological abnormalities:

6.4.1 Abnormal physical findings. [B]

6.4.2 Decreasing intragraft blood flow (<600 mL/min). [B]

6.4.3 Elevated static pressure within the graft. [B]

6.5 Outcomes after treatment of stenosis without thrombosis:
After angioplasty or surgical revision of a stenosis, each institution should monitor the primary patency of the AVG. Reasonable goals are as follow:

6.5.1 Angioplasty:

6.5.1.1 The treated lesion should have less than 30% residual stenosis and the clinical/physiological parameters used to detect the stenosis should return to acceptable limits after the intervention. [B]

6.5.1.2 A primary patency of 50% at 6 months. [B]

6.5.2 Surgical revision:

6.5.2.1 The clinical/physiological parameters used to detect the stenosis should return to acceptable limits after the intervention. [B]

6.5.2.2 A primary patency of 50% at 1 year. [B]

6.6 If angioplasty of the same lesion is required more than 2 times within a 3-month period, the patient should be considered for surgical revision if the patient is a good surgical candidate.

6.6.1 If angioplasty fails, stents may be useful in the following situations:

6.6.1.1 Surgically inaccessible lesion. [B]

6.6.1.2 Contraindication to surgery. [B]

6.6.1.3 Angioplasty-induced vascular rupture. [B]

6.7 Treatment of thrombosis and associated stenosis:

Each institution should determine which procedure, percutaneous thrombectomy with angioplasty or surgical thrombectomy with AVG revision, is preferable based upon expediency and physician expertise at that center.

6.7.1 Treatment of AVG thrombosis should be performed urgently to minimize the need for a temporary HD catheter. [B]

6.7.2 Treatment of AVG thrombosis can be performed by using either percutaneous or surgical techniques. Local or regional anesthesia should be used for the majority of patients. [B]

6.7.3 The thrombectomy procedure can be performed in either an outpatient or inpatient environment. [B]

6.7.4 Ideally, the AVG and native veins should be evaluated by using intraprocedural imaging. [B]

6.7.5 Stenoses should be corrected by using angioplasty or surgical revision. [B]

6.7.6 Methods for monitoring or surveillance of AVG abnormalities that are used to screen for venous stenosis should return to normal after intervention. [B]

6.8 Outcomes after treatment of AVG thrombosis:

After percutaneous or surgical thrombectomy, each institution should monitor the outcome of treatment on the basis of AVG patency. Reasonable goals are as follows:

6.8.1 A clinical success rate of 85%; clinical success is defined as the ability to use the AVG for at least 1 HD treatment. [B]

6.8.2 After percutaneous thrombectomy, primary patency should be 40% at 3 months. [B]

6.8.3 After surgical thrombectomy, primary patency should be 50% at 6 months and 40% at 1 year. [B]

6.9 Treatment of AVG infection:
Superficial infection of an AVG should be treated as follows:

6.9.1 Initial antibiotic treatment should cover both gram-negative and gram-positive microorganisms. [B]

6.9.1.1 Subsequent antibiotic therapy should be based upon culture results.

6.9.1.2 Incision and drainage may be beneficial.

6.9.2 Extensive infection of an AVG should be treated with appropriate antibiotic therapy and resection of the infected graft material. [B]

Guideline 7. Prevention and Treatment of Catheter and Port Complications

Catheters and ports are essential tools for providing urgent and, in some cases, long-term vascular access. Prevention and early treatment of complications should greatly reduce associated morbidity and mortality.

7.1 Catheters and ports should be evaluated when they become dysfunctional. Dysfunction is defined as failure to attain and maintain an extracorporeal blood flow of 300 mL/min or greater at a prepump arterial pressure more negative than –250 mm Hg. [B]

Signs of CVC Dysfunction: Assessment Phase

Definitions: CVC; central venous catheter; URR, urea reduction ratio; Kt/V, (K_urea x T_d)/V_urea, where K_urea is the effective (delivered) dialyzer urea clearance in milliliters per minute integrated over the entire dialysis, T_d is the time in minutes measured from beginning to end of dialysis, and V_urea is the patient's volume of urea distribution in milliliters

Causes of Early Catheter Dysfunction

Definitions: IV IgG, intravenous Immunoglobulin G

Available Thrombolytics

7.2 The exception is pediatric or smaller adult catheters that are not designed to have flows in excess of 300 mL/min. [B]

7.3 Methods that should be used to treat a dysfunctional or nonfunctional catheter or port include:

7.3.1 Repositioning of a malpositioned catheter. [B]

7.3.2 Thrombolytics, using either an intraluminal lytic, intradialytic lock protocol, or an intracatheter thrombolytic infusion or interdialytic lock. [B]

7.3.3 Catheter exchange with sheath disruption, when appropriate. [B]

7.4 Treatment of an infected HD catheter or port should be based on the type and extent of infection.

7.4.1 All catheter-related infections, except for catheter exit-site infections, should be addressed by initiating parenteral treatment with an antibiotic(s) appropriate for the organism(s) suspected. [A]

7.4.2 Definitive antibiotic therapy should be based on the organism(s) isolated. [A]

7.4.3 Catheters should be exchanged as soon as possible and within 72 hours of initiating antibiotic therapy in most instances, and such exchange does not require a negative blood culture result before the exchange. [B] Follow-up cultures are needed 1 week after cessation of antibiotic therapy (standard practice).

7.4.4 Port pocket infections should be treated with systemic antibiotics and irrigation, in conjunction with the manufacturers' recommendations. [B]

Guideline 8. Clinical Outcome Goals

8.1 Goals of access placement:

8.1.1 Each center should establish a database and CQI process to track the types of accesses created and complication rates for these accesses.

8.1.2 The goals for permanent HD access placement should include:

8.1.2.1 Prevalent functional AVF placement rate of greater than 65% of patients. [B]

8.1.2.2 Cuffed catheter for permanent dialysis access (e.g., not as a bridge) in less than 10% of patients. Long-term catheter access is defined as the use of a dialysis catheter for more than 3 months in the absence of a maturing permanent access - graft or fistula. [B]

8.2 The primary access failure rates of HD accesses in the following locations and configurations should not be more than the following:

8.2.1 Forearm straight grafts: 15%. [B]

8.2.2 Forearm loop grafts: 10%. [B]

8.2.3 Upper-arm grafts: 5%. [B]

8.2.4 Tunneled catheters with blood flow less than 300 mL/min: 5%. [B]

8.3 Access complications and performance:

8.3.1 Fistula complications/performance should be as follows:

8.3.1.1 Fistula thrombosis: fewer than 0.25 episodes/patient-year at risk. [B]

8.3.1.2 Fistula infection: less than 1% during the use-life of the access. [B]

8.3.1.3 Fistula patency greater than 3.0 years (by life-table analysis). [B]

8.3.2 Graft complications/performance should be as follows:

8.3.2.1 Graft thrombosis: fewer than 0.5 thrombotic episodes/patient-year at risk. [B]

8.3.2.2 Graft infection: less than 10% during the use-life of the access. [B]

8.3.2.3 Graft patency greater than 2 years (by life-table analysis). [B]

8.3.2.4 Graft patency after PTA: longer than 4 months. [B]

8.3.3 Catheter complications/performance should be as follows:

8.3.3.1 Tunneled catheter-related infection less than 10% at 3 months and less than 50% at 1 year. [B]

8.3.3.2 The cumulative incidence of the following insertion complications should not exceed 1% of all catheter placements: [B]

• Pneumothorax requiring a chest tube

• Symptomatic air embolism

• Hemothorax

• Hemomediastinum

• Hematoma requiring evacuation

8.3.4 Cumulative patency rate of tunneled cuffed catheters (TCCs): Not specified. [B]

8.4 Efficacy of corrective intervention:

The rate of certain milestones after correction of thrombosis or stenosis should be as follows:

8.4.1 AVF patency after PTA: greater than 50% unassisted patency at 6 months (and <30% residual stenosis postprocedure or lack of resolution of physical findings postprocedure); AVF patency following surgery: greater than 50% unassisted patency at 1 year. [B]

8.4.2 AVG patency after PTA: please refer to CPG 6.5.1

AVG patency after surgery: please refer to CPG 6.5.2

AVG after either PTA or surgery: greater than 90% with postprocedure restoration of blood flow and greater than 85% postprocedure ability to complete 1 dialysis treatment. Please refer to CPG 6.8. [B]

8.4.3 Surgical correction is set to a higher standard because of the use of venous capital. [B]

Clinical Practice Recommendations for Vascular Access

Clinical Practice Recommendations for Guideline 1: Patient Preparation for Permanent Hemodialysis Access

Factors that may be helpful in preparing the patient for placement of a permanent HD access include the following:

1.1 The veins of the dorsum of the hand should be the preferred site for IV cannulation.

1.2 Sites for venipuncture should be rotated if arm veins need to be used.

1.3 Patients with CKD stage 5 should be educated on the risks and benefits associated with catheters and strongly encouraged to allow the evaluation for and creation of a fistula for long-term access when appropriate. Such discussions with the patient should be initiated months before the anticipated start of dialysis therapy.

1.4 Alternative imaging studies for central veins include Duplex Doppler ultrasound (DDU) and magnetic resonance imaging/magnetic resonance angioography (MRA).

Clinical Practice Recommendations for Guideline 2: Selection and Placement of Hemodialysis Access

Recommendations for fistulae:

2.1 When a new native fistula is infiltrated (i.e., presence of hematoma with associated induration and edema), it should be rested until the swelling is resolved.

Clinical Practice Recommendations for Guideline 3: Cannulation of Fistulae and Grafts and Accession of Dialysis Catheters and Ports

3.1 Cannulation skill:

Staff should be appropriately trained and observed for technical mastery before cannulating any AV access. Only those with said technical mastery should be allowed to cannulate a new fistula. A protocol for minimizing vessel damage should be used for cannulation failure. Recannulation should be attempted only when the cannulation site is healed and the vessel is assessed to be normal and appropriate for cannulation. Heparin management should be reviewed on a case-by-case basis to minimize postdialysis bleeding.

3.2 Self-cannulation:

Patients who are capable and whose access is suitably positioned should be encouraged to self-cannulate. The preferred cannulation technique is the buttonhole.

3.3 Buttonhole:

Patients with fistula access should be considered for buttonhole (constant-site) cannulation. (See protocol in CPG 3.)

3.4 Elevation of arm for swelling:

The AVG access arm should be elevated as much as possible until swelling subsides, which may take as long as 3 to 6 weeks. Increase in symptoms requires urgent evaluation.

Clinical Practice Recommendations for Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing

4.1 Monitoring the access:

4.1.1 Access patency should be ensured before each treatment before any attempts to cannulate the access.

4.1.2 All caregivers, including fellows in training, should learn and master the methods for examining a vascular access.

4.1.3 Access characteristics, such as pulsatility and presence of thrill, as well as flow and pressure, should be recorded and tracked in a medical record and be available to all caregivers of the vascular access team (VAT).

4.2 Frequency of measurement is dependent on the method used:

4.2.1 It is not clear that access flow measurements performed at a monthly frequency provide sufficient data stability to make decisions. Until additional studies are performed to determine the optimal frequency, more frequent measurements are recommended.

4.2.2 Static pressure measurements require less technology and should be made more frequently than flow measurements. Direct measurements of static pressure ratios should be made every 2 weeks. Less-direct measurements should be made weekly. Dynamic pressures, if used (see CPG 4.2.3), should be measured with each dialysis treatment, but derivation of a static pressure should be attempted, rather than using the raw numbers.

4.2.3 Measurement of recirculation is not recommended as a surveillance technique in grafts.

4.3 Frequency of measurement for access complications:

4.3.1 Thrombosis in fistulae develops more slowly than in grafts. Flow measurements performed at a monthly frequency appear to be adequate. Until additional studies are performed to determine the optimal frequency, less frequent measurements are not recommended.

4.3.2 Because static pressure measurements are inherently less accurate in detecting access stenosis in fistulae, the frequency should not be less than in grafts. Direct measurements of static pressure ratios should be made every 2 weeks. Less-direct measurements should be made weekly. Dynamic pressures should be measured with each dialysis. Increased recirculation can indicate reduced effective blood pump flow, resulting in inadequate dialysis.

4.4 Diagnostic testing:

4.4.1 Characteristics of access (see CPR 4.1), as well as blood pump flow and pressure performance, should be recorded and tracked in medical records.

4.4.2 Data should be analyzed at least monthly to evaluate access dysfunction.

4.4.3 After intervention, the surveillance parameter should be restored to normal.

4.4.4 Data should be analyzed to improve success rates and ensure that interventions are appropriately assessed. For example, PTA and surgical revision rates, recurrence rates, and number of procedures per patient year should be systematically analyzed in a CQI process.

4.4.5 A multidisciplinary team should be involved.

4.4.6 Preemptive correction of hemodynamically significant stenoses should remain the standard of care.

Clinical Practice Recommendations for Guideline 5: Treatment of Fistula Complications

5.1 If a new fistula access has vein margins that are difficult to discern on physical examination and cannulation frequently is associated with aspiration of clot, the patient should be referred for access marking by means of DDU to define the center of the vessel and depth of the fistula. A diagram of these findings should be sent to the dialysis unit.

5.1.1 The patient should be taught to examine his or her access daily, while at home, for thrombosis.

Clinical Practice Recommendations for Guideline 7: Prevention and Treatment of Catheter and Port Complications

7.1 Treatment of catheter dysfunction:

Catheter dysfunction should be treated when a dialyzer blood flow of 300 mL/min is not being attained in a catheter previously able to deliver greater than 350 mL/min at a prepump pressure of –250 torr.

7.1.1 A dysfunctional catheter (blood flow <300 mL/min) for 2 consecutive treatments should be treated in the HD unit by using an intraluminal interdialytic thrombolytic lock protocol between 2 dialysis treatments (i.e., 35 to 69 hours).

7.2 Radiological evaluation:

Any dysfunction that cannot be managed in the dialysis unit should be sent for radiographic study to diagnose dysfunction and document the condition of the vessel.

7.2.1 Catheter imaging with contrast infusion can identify other correctable problems (e.g., residual lumen thrombus, external fibrin catheter sheath, malpositioned catheter tip). Appropriate interventions may follow, such as:

7.2.1.1 Repositioning of the catheter.

7.2.1.2 Angioplasty of a vessel.

7.2.1.3 Replacement of a malpositioned catheter over guide wire.

7.2.1.4 Higher-dose lytic infusion for occlusive thrombus (e.g., right atrial) or fibrin sheath

7.3 Choice of thrombolytic and use of other modalities:

7.3.1 A special brush is used to remove thrombus from the lumens of a conventional catheter by using a protocol specific to this procedure.

7.4 Treatment of infection:

7.4.1 Catheter exit-site infections, in the absence of a tunnel infection, should be treated with topical and/or oral antibiotics, ensuring proper local exit-site care. In general, it should not be necessary to remove the catheter.

7.4.2 If a patient with bacteremia is afebrile within 48 hours and is clinically stable, catheter salvage might be considered by using an interdialytic antibiotic lock solution and 3 weeks of parenteral antibiotics in appropriate situations. A follow-up blood culture 1 week after completion of the course of antibiotics should be performed. (see Table 24 in the original guideline document)

7.4.3 Antibiotic lock with antibiotic to which the organism is sensitive is indicated when follow-up cultures indicate reinfection with the same organism in a patient with limited catheter sites.

7.4.4 Short-term catheters should be removed when infected. There is no conclusive evidence to support a rationale for scheduled replacement except for those in the femoral area.

Clinical Practice Recommendation 8: Vascular Access in Pediatric Patients

8.1 Choice of access type:

8.1.1 Permanent access in the form of a fistula or graft is the preferred form of vascular access for most pediatric patients on maintenance HD therapy.

8.1.2 Circumstances in which a central venous catheter (CVC) may be acceptable for pediatric long-term access include lack of local surgical expertise to place permanent vascular access in small children, patient size too small to support a permanent vascular access, bridging HD for PD training or PD catheter removal for peritonitis, and expectation of expeditious kidney transplantation.

8.1.3 If surgical expertise to place permanent access does not exist in the patient's pediatric setting, efforts should be made to consult vascular access expertise among local adult-oriented surgeons to either supervise or place permanent vascular access in children.

8.1.4 Programs should evaluate their patients' expected waiting times on their local deceased-donor kidney transplant waiting lists. Serious consideration should be given to placing permanent vascular access in children greater than 20 kg in size who are expected to wait more than 1 year for a kidney transplant.

Semipermanent HD Catheter and Patient Size Guideline

8.2 Stenosis surveillance:

An AVG stenosis surveillance protocol should be established to detect venous anastomosis stenosis and direct patients for surgical revision or PTA.

8.3 Catheter sizes, anatomic sites, and configurations:

8.3.1 Catheter sizes should be matched to patient sizes with the goal of minimizing intraluminal trauma and obstruction to blood flow while allowing sufficient blood flow for adequate HD.

8.3.2 External cuffed access should be placed in the internal jugular with the distal tip placed in the right atrium.

8.3.3 The blood flow rate (BFR) of an external access should be minimally 3 to 5 mL/kg/min and should be adequate to deliver the prescribed HD dose.

Definitions:

Rating the Strength of Guideline Recommendations

The strength of each guideline recommendation is based on the quality of the supporting evidence as well as additional considerations. Additional considerations, such as cost, feasibility, and incremental benefit were implicitly considered.

A It is strongly recommended that clinicians routinely follow the guideline for eligible patients. There is strong evidence that the practice improves health outcomes.

B It is recommended that clinicians routinely follow the guideline for eligible patients. There is moderately strong evidence that the practice improves health outcomes.

CPR It is recommended that clinicians consider following the guideline for eligible patients. This recommendation is based on either weak evidence or on the opinions of the Work Group and reviewers that the practice might improve health outcomes.

Health outcomes are health-related events, conditions, or symptoms that can be perceived by individuals to have an important effect on their lives. Improving health outcomes implies that benefits outweigh any adverse effects.

Rating the Quality of Evidence

The quality of evidence was not explicitly graded. It was implicitly assessed according to the criteria outlined in the table below, and considered: i) the methodological quality of the studies; ii) whether or not the studies were carried out in the target population (i.e., patients on dialysis, or in other populations) and iii) whether the studies examined health outcomes directly, or examined surrogate measures for those outcomes (e.g., blood flow instead of access survival.)

• Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006 Jul;48 Suppl 1:S248-73. PubMed

Electronic copies: Available from the National Kidney Foundation (NKF) Web site.

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