KDOQI (Kidney Disease Outcomes Quality Initiative)
NKF KDOQI GUIDELINES

Executive Summaries | Anemia | Hemodialysis | Peritoneal Dialysis |
Vascular Access | Nutrition | CKD 2002 | Dyslipidemias | Bone Metabolism | Hypertension and Antihypertensive Agents | Cardiovascular Disease in Dialysis Patients | History of KDOQI | Pediatric Bone | Anemia 2006 |
Updates 2006

Clinical Practice Guidelines and Clinical Practice Recommendations
2006 Updates
Hemodialysis Adequacy
Peritoneal Dialysis Adequacy
Vascular Access


CLINICAL PRACTICE GUIDELINES FOR VASCULAR ACCESS

III. RESEARCH RECOMMENDATIONS

PREAMBLE

RCTs are the optimal study design to answer intervention questions. A recent review concluded that between 1966 and 2002, the number of RCTs published in nephrology from 1966 to 2002 (2,779) is fewer than in all other specialties of internal medicine.629 In addition, the overall quality of RCT reporting in nephrology is low and has not improved for 30 years. Issues identified included unclear allocation concealment (89%), lack of reported blinding of outcome assessors (92%), and failure to perform “intention-to-treat analysis” (50%). The challenges of improving the quality and quantity of trials in nephrology are substantial. We need to use standard guidelines and checklists for trial reporting, give greater attention to trial methods, and cease to focus on results of small underpowered studies. We must involve experts in trial design and reporting, expect multicenter collaboration, and do larger, but simpler, trials. Many of the research recommendations made in this section require multicenter trials to enroll sufficient patients to obtain clear-cut answers. Many will not receive external support from government or other grant agencies. However, they can be performed by collaboration between those in academic centers and those in clinical practice. We should emulate cardiology, for which there has been a 6-fold growth in clinical research trials, particularly in the number of patients (usually in the thousands) enrolled into the studies.

RANKING OF RECOMMENDATIONS
Research recommendations have been grouped into 3 categories: critical research, important research, and research of interest. These rankings were made by the Work Group based on current evidence and the need for research to provide additional evidence for the current CPGs and CPRs. No attempt was made to rank research recommendations within each of the 3 research categories.

Although the Vascular Access Work Group was restricted by the NKF to a thorough literature review in only 4 areas, the Work Group has developed research questions for all CPGs. These questions should not be viewed as comprehensive, but as a stimulus to the nephrology community to begin to ask, hopefully, better questions regarding vascular access with a goal of better outcomes for our patients.

CRITICAL RESEARCH RECOMMENDATIONS
Guideline 1. Patient Preparation for Permanent HD Access
Studies are required to determine the optimal vascular mapping criteria based on outcome goals of working fistulae.

Studies are needed to determine the optimal stratification of patients for fistula placement. Is there an age component to sizing of the artery and vein for fistula creation? Specifically, should the minimal vein diameter for such higher risk groups as female, diabetic, and elderly patients be larger to have acceptable working fistula outcomes?

Randomized studies should be performed comparing 1-stage with 2-stage brachial basilic vein transposition fistula outcomes.

Studies are needed to determine the optimal surgical techniques for fistula creation with outcomes to identify factors that minimize the development of surgical swing segment stenosis in fistulae.

Guideline 2. Selection and Placement of HD Access
Patients should be considered for construction of a primary fistula after failure of every HD access. There is a paucity of information about the success of this strategy. If a forearm loop AVG is placed as initial access, does this lead to successful construction of elbow-level fistulae? How often? Do we need an RCT? In what patients would a graft before fistula be cost- and resource effective? None? Some? Would a PU “immediate use” type of graft be preferable to a catheter if one had to do immediate (ie, within days) dialysis?

How often is primary conversion of dysfunctional grafts to fistulae successful? Is it affected by the previous history of thrombosis or angioplasty (if applicable)? What are the guidelines for number of angioplasties/thrombectomies performed before compromising the ability to convert to a fistula? What is the optimal timing for conversion?

The preference for fistulae is based on lower morbidity associated with their creation and maintenance compared with other access types. Is this still true for the US CKD stage 5 population?

Has this remained true as the population has grown older and the health care system in the United States has been stretched? Late referrals, lower skill sets in the staff delivering dialysis and cannulating accesses, increased comorbidity in the United States compared with Europe, Japan, or Canada—do these factors influence the selection of initial access and the progression and choices among different access types?

Guideline 3. Cannulation of Fistulae and Grafts and Accession of HD Catheters and Port Catheter Systems
Can intensive structured cannulation training lead to better access outcomes?
Can increased remuneration for expert cannulators lead to better access outcomes?
Can self-cannulation lead to better outcomes?

Guideline 4. Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Studies are needed to compare outcomes of physical examination with “high-tech” methods in determining the best timing for intervention.

The role of DDU as an intermediate diagnostic test should be examined to determine the “timing” for access intervention with PTA or surgery.

There may be important differences in the susceptibility of grafts and fistulae to thrombosis as a function of absolute access flow or change in access flow over time. The “best” therapy for the access also may differ according to type. Future studies should carefully separate the surveillance data, type of intervention (PTA or surgical), response to therapy, and both short-term and long-term outcomes according to access type, either graft or fistula. Because more proximal accesses have greater flow rates, data also should be categorized to access location, primarily the feeding artery (radial or ulnar versus low brachial, high brachial, and axillary for the upper arm and femoral for the thigh).

Studies are needed to establish objective criteria for endovascular intervention.

Guideline 5. Treatment of Fistula Complications
The efficacy of physical examination in detecting abnormalities in accesses difficult to cannulate should be studied.

Comparative trials are required to assess interventional versus surgical modalities to correct maturation failure with measurement of access flow longitudinally before and after correction.

Studies should examine the effect of intervention on: recurrent stenosis, elastic recoil, and juxta-anastomotic stenoses.

Guideline 6. Treatment of AVG Complications
Assessing adequacy of the intervention. Is PTA an effective intervention for treatment of vascular access–related stenosis? We cannot answer this question. A fundamental problem is our inability to reliably predict the outcomes of our percutaneous and surgical interventions. The true determinants of HD graft patency and longevity remain unknown. It certainly is a complex and multifactorial process. The primary determinants of graft failure likely are regulated by both physiological and genetic factors and therefore are variable within the patient population. To add to the confusion, neointimal hyperplastic stenoses develop simultaneously and sequentially in multiple locations. Our success in treating 1 stenosis is negated by the rapid development of another lesion. And there is another important variable: delayed elastic recoil can cause rapid recurrence of the stenosis after an apparently successful angioplasty procedure. This phenomenon can occur minutes to hours after balloon dilation, and our anecdotal experience suggests that elastic recoil of a stenosis may happen after 10% to 15% of our angioplasty procedures. Our current challenge is to identify the determinants for successful angioplasty and optimize our techniques to improve our clinical outcomes. In addition, we need to develop pharmacological means to reduce/prevent the recurrence of neointimal hyperplasia after successful angioplasty.

Criteria for success. An end point is used to define the successful completion of a procedure. The definition of a successful procedure can be viewed from several different perspectives. For example, the end point for clinical success is alleviation of the patient's symptoms. Hemodynamic success is restoration of normal blood flow throughout the treated vascular segment. And for treatment of stenoses, the end point for anatomic success is less than 30% residual diameter reduction. These clinical, hemodynamic, and anatomic end points serve as the determinants of a successful endovascular intervention. Our clinical experience has shown that these commonly used end points are unreliable for predicting the long-term patency of an HD graft or fistula. Although we use end points to define immediate success, there is no postprocedural end point that correlates with long-term patency. Our inability to predict the long-term outcome of our endovascular procedures continues to frustrate both the physician and patient.

After an endovascular intervention, the standard definition of anatomic success is a residual stenosis with less than 30% diameter reduction. Although there are well-recognized physiological concepts that support the use of 50% stenosis as the definition of a hemodynamically significant lesion, there is no such scientific basis for the use of less than 30% residual stenosis to define a successful treatment. A consensus committee reached the value of 30% with representatives from interventional radiology and vascular surgery. This well-accepted standard end point (<30% residual stenosis) has no hemodynamic or physiological meaning. In addition, the residual stenosis does not allow for proper remodeling of the vein and may contribute to recurrence of stenosis. Therefore, it is not surprising that use of this parameter as a determinant of success is not predictive of the long-term patency of an HD graft or fistula. This poor correlation between degree of residual stenosis and subsequent patency was substantiated in a study that reported analysis of 96 interventions performed in native AVFs.630 After angioplasty, 17 lesions had greater than 30% residual stenosis and, by definition, had failed treatment. However, there was no difference in the long-term patency of this group compared with patients who had lesions with less than 30% residual stenosis on final fistulography.

Obviously, criteria used for success need to be examined by well-designed outcome studies.

Multiple lesions and criteria for intervention. According to the KDOQI guidelines, lesions with less than 50% stenosis should not be treated. However, it is not uncommon for a graft or fistula to have multiple areas of endoluminal irregularity that, when measured individually, represent less than 50% stenosis and therefore should not be treated. However, a hemodynamic abnormality may still exist. The basic principles of hemodynamics state that the effects of multiple stenoses are additive, similar to an electrical circuit with a series of multiple resistors. Therefore, our current concepts that emphasize the evaluation of individual stenoses using anatomic criteria are flawed.

New methods54 that provide a more global assessment of the entire vascular access circuit suggest that subtle lesions can have substantial hemodynamic effects. The assessment of intragraft blood flow during angioplasty procedures may provide additional information regarding the hemodynamic importance of lesions that are greater than 30% but less than 50% stenosis.

We need to identify physiological/objective criteria for successful intervention.

IMPORTANT RESEARCH RECOMMENDATIONS

Guideline 1. Patient Preparation for Permanent HD Access
Studies are needed to determine the optimum timing of access placement.

Studies should be performed to examine the effect of exercises to mature vessels (arterial and venous) before and after fistulae are constructed.

The use of diluted contrast to characterize the venous system peripherally and centrally in patients with CKD and the effect on residual kidney function should be studied.

Additional studies are needed to compare the accuracy of MRA and DDU in evaluating central veins.
How can we align incentives for the creation of fistulae for all stakeholders: patients, nephrologists, surgeons, and dialysis providers?

Guideline 2. Selection and Placement of HD Access
What is the relative benefit of arm exercises performed before or after fistula construction and maturation or both?

We need RCTs to determine the effect of exercise either before or after access construction, alone or combined, on access maturation, time to cannulation, primary and secondary patency, ease of cannulation, number of procedures needed during the life span of the access, and cost analysis. Is pressure inside the fistula important in the maturation process? Is it flow or intraconduit pressure or both that allow an access to tolerate cannulation without infiltration? Should a nonocclusive tourniquet be used during exercise? Do we use/measure mere clinical end points for these studies or does fistula flow need to be measured as well, or does it not matter what the flow is? Brachial artery flow can be measured as a surrogate for access flow.

If intrafistula flow is important, what flow is needed to mature a fistula?

Guideline 3. Cannulation of Fistulae and Grafts and Accession of HD Catheters and Port Catheter Systems
Additional studies are needed of disinfectants, the role of antibiotic locks, and which patients may benefit most from CVC salvage. Risk-benefit outcomes, as well as long-term antibiotic susceptibility studies, should be done to detect resistance.

Studies are needed to examine the effectiveness of data on rotation of sites, buttonhole, flow/pressure curves, and so on.
Does the bevel-up cannulation method decrease access complications?

What needle tip-to-tip measurements minimize recirculation or prevent erroneous access flow measurements?
Can buttonhole (constant-site) cannulation be used in biografts?

Should an infiltrating needle be removed after the patient undergoes sytemic anticoagulation with heparin?

How should the timing of flushing and locking of heparin in a catheter occur in a patient who is using 1 needle in the fistula and 1 side of the catheter for return?

Do transparent dressings, where the exit site is clearly visualized, need to be changed at each dialysis treatment?

Guideline 4. Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Further evaluation of the acoustic stethoscope is needed in detecting hemodynamically significant stenoses.

The relationship of access flow to pressure varies among individuals, affected chiefly by the health and capacity of the artery to deliver flow into the access. Within a population, there may be no obvious relationship between access flow and PIA if measurements are made cross-sectionally because the important determinant in an individual is baseline flow (which may vary from 500 to 3,000 mL/min), the presence of 1 or more stenoses, their location, and the rate of evolution of the stenosis or stenoses. Additional studies are needed to determine the natural course of stenoses in grafts and fistulae. Stable stenoses may need no intervention if they are not associated with increased risk for thrombosis. Conversely, there may be significant risk for thrombosis, even with access flows exceeding 1,000 mL/min. Noninterventional trials should be conducted with the clock starting from the time of construction.

Large-scale trials are required to determine whether correction only of “hemodynamically” significant lesions (those associated with “low” access flows or “high” pressures or a change in access flow or pressure) is superior to correction of all stenosis greater than 50%.

Guideline 5. Treatment of Fistula Complications
Studies are required to compare strategies for treating aneurysms in fistula: surgery with new anastomosis versus surgical creation of new anastomosis. Cost and outcome analyses should be performed.

Studies are needed to examine the efficacy of endoluminal interventional versus surgical procedures for the management of aneurysms in fistulae.

Comparative trials should be performed to study the efficacy of surgery compared with interventional endoluminal procedures in correcting stenoses/thrombosis, with the same methods used for outcomes.

The role of thrombolytics in reestablishing or maintaining patency after fistula thrombosis should be examined. Low doses of thrombolytics have been used to keep costs controlled—does it make a difference in outcomes?

Data from RCTs are needed on the duration of thrombosis and success in reestablishing/maintaining patency. Is surgery more effective early or later?

Guideline 6. Treatment of AVG Complications
Assessing effectiveness of interventions. It is well accepted that a stenosis causing greater than 50% diameter reduction is considered to be a hemodynamically significant lesion. This value is based on both experimental modeling of flow stenosis631 and correlation of thrombosis rates and degree of stenosis.10 This value is based upon the physiology of a “critical arterial stenosis.”450,451 A 50% reduction in luminal diameter corresponds to a 75% reduction in cross-sectional area, the critical point at which blood flow begins to dramatically decrease.

Measuring technical success. What determines technical success for endovascular interventions? Should technical success be based upon anatomic criteria, the measurement of which is both subjective and fraught with error and usually not assessed in 2 orthogonal views? Or should it be based upon normalization of a hemodynamic parameter that is less subjective and more reflective of vascular access performance? Possibilities include the use of flow measurements, static pressure, or ultrasound imaging during the PTA procedure or angioscopy after the procedure. Continued clinical investigation hopefully will provide scientific support for the use of hemodynamic end points, not anatomic end points.

Endovascular stents would seem to be an ideal method to treat angioplasty failures. Stents can oppose elastic recoil and optimize endoluminal dimensions, thereby improving intragraft blood flow and prolonging graft patency. However, the majority of clinical studies showed that the routine use of stents does not provide an additional benefit compared with angioplasty alone.460,461 The neointimal hyperplastic tissue continues to grow unabated through the meshwork of the metallic stent. For these reasons, use of endovascular stents to treat HD-related stenoses continues to be a controversial subject. A recent study reported that use of nitinol stents provided superior results compared with stainless steel stents.632 Continued improvements in stent design, the use of stent grafts, or the use of drug-eluting stents may provide better long-term results. Covered stents have been used to salvage AVGs, but efficacy has not been compared with other strategies.

Balloon sizing and selection. Balloons are now available in various sizes, have cutting edges, and are capable of delivering drugs. The proper selection and use of these balloons requires additional studies.

Mechanical thrombectomy devices. Comparative studies are needed on efficacy and cost. A reanalysis of existing data with differing devices should be performed.

Thrombolytics and anticoagulation.
Although heparin typically is used during an endoluminal thrombectomy procedure, the proper role of thrombolytics is unknown. The spectrum has shifted from pharmacolytic to mechanical thrombectomy. Whether some lytics and their efficacy are superior to others in terms of outcomes is unknown. Several small series also suggested that dialysis within hours of thrombectomy influences patency.

Comparison of intervention methods. Do percutaneous and surgical techniques provide similar results or are we using percutaneous techniques simply because of the unavailability of surgical manpower for performing large numbers of vascular access–related procedures in an expedient manner? From another perspective, are we sacrificing long-term patency of the AVG to avoid insertion of an HD catheter?

Several reasonable studies reported that surgical techniques for AVG repair can provide substantially better outcomes compared with percutaneous techniques.467,468,472 By establishing substantially higher primary patency goals after surgical repair, the KDOQI guidelines have acknowledged the superiority of surgical techniques. However, because of a variety of factors, including the unavailability of surgeons, the growth of interventional nephrology, the trend toward outpatient vascular access services, and the profitability of percutaneous procedures, the superiority of surgical techniques seems to have been forgotten.

Do surgical techniques for AVG repair provide more durable results with better long-term patency compared with percutaneous techniques? Is this a political issue, a manpower issue, or a financial issue?

Prevention of stenosis. This is a particularly important area. Both basic studies and pharmaceutical interventions are needed.

Guideline 7. Prevention and Treatment of Catheter and Port Complications
The ideal catheter diameter is not established. Are there concomitantly increased complications associated with larger diameter catheters?

Studies are needed to evaluate the risk versus benefit of higher dose warfarin therapy (INR > 1.6) on catheter patency.

A comparison of lytic treatments is needed to examine:

  1. Comparison of heparin at different concentrations (1,000 U and 5,000 U/mL) for all 3 dialysis sessions per week versus substitution of one of the heparin locks by tPA lock
  2. Use of high dose tPA (2.5-5 mg/lumen) where the catheter blood flow delivered at −250 mm Hg falls to <300 mL/min or decreases by 100 mL/min from its best flow ever

A definitive study should be performed to determine the natural history of catheter/port-related complications in the central veins, by using central venograms, that begins with de novo catheter placement, every 6-month follow-up, and with each catheter complication (CRB, fibrin sheath, and all other types of catheter dysfunction).

Studies are needed to determine the association between infection and fibrin sheaths in catheters.

The optimal duration of antibiotic therapy for catheter-related infections should be examined.

Prospective studies are needed to examine antibiotic locks as an adjunct to save catheter versus “site salvage.” Outcomes as primary and economics as secondary factors should be considered.

RESEARCH RECOMMENDATIONS OF INTEREST

Guideline 1. Patient Preparation for Permanent HD Access
Does patient education on the various risks/benefits of catheters versus fistulae/grafts alter success in placement? Is it an ethical study?

What demographic variables influence the likelihood of permanent access construction among a cohort of patients seen in a CKD clinic?

Guideline 2. Selection and Placement of HD Access
Studies are needed to determine the optimum duration of rest of a young (in use for <3 months) fistula after it has been infiltrated (ie, presence of hematoma with associated induration and edema). What parameters should be examined and how should such a study be designed?

The effects of catheter tip location on catheter or port catheter system performance should be studied—in the SVC/right atrium, common iliac, low IVC, and high IVC/right atrium. For the same French and luminal diameter, pressure flow curves should be performed keeping catheter design constant (ie, without mixing stepped and split catheters).

Studies are required to examine the effect of jets from catheter tips on central veins.

Guideline 3. Cannulation of Fistulae and Grafts and Accession of HD Catheters and Port Catheter Systems
What effect does correction of anemia have on access flow in fistulae? Prospective observational studies are needed.

Guideline 4. Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Research is needed on portable ultrasound devices for assessing flow easily and repetitively without operator effects.

Studies are needed to determine whether a properly performed DVP test retains any utility in detecting stenoses in fistulae.

Comparisons of surveillance techniques (access flow, DVP, PIA) are required in fistulae using DDU anatomic imaging or contrast angiography to determine sensitivity and specificity. Low-end techniques (physical examination + derived PIA± flow achieved/prepump pressure) should be compared with high-end methods (QA by UDT or GPT alone ± flow by in-line dialysance, DDU).

Guideline 5. Treatment of Fistula Complications
Comparative trials are needed to examine interventional versus surgical modalities to correct maturation failure, with measurement of access flow longitudinally before and after correction.

Guideline 6. Treatment of AVG Complications
Treatment of infection. There are few informative data on the treatment of infected grafts. Decisions on using antibiotics, removal or not of the AVG, and duration of antibiotic use usually are made based on experimental considerations and recommendations from infectious disease consultants and CDC publications. Most of these recommendations are extrapolations and are not based on specific studies of dialysis patients with AVGs.

Arterial lesions and steal. In an increasingly older population with a greater incidence of diabetes, arterial lesions are not uncommon in patients undergoing vascular access constructions.409 Steal occurs with high-flow fistulae. Prediction of its occurrence80,633 and means to prevent its development634 require prospective outcome studies. Once developed, several methods can be used to correct the problem,411,431,433,635,636 but without consensus about the best procedure.48,637 When distal digital ischemic changes or gangrene appear ipsilateral to a functioning graft, we need more studies to determine whether the problem is purely “ischemic” or perhaps embolic.431,638

Prediction of successful AVG function. A multitude of factors probably influence the longevity of AVG function,143 including the individual's genetic predisposition for neointimal hyperplasia, surgical techniques, cannulation, and so on. These factors have not been systemically studied.

Guideline 7. Prevention and Treatment of Catheter and Port Complications
Studies should examine the value of sequential measurement of dialyzer flow rates and delivered and prepump arterial pressures during sequential dialysis treatments in detecting problems while they are still amenable to pharmacological or mechanical intervention. With modern catheters, what is the value of the conductance (BFR/arterial prepump pressure) in predicting catheter dysfunction?

Research is needed to define the optimum value of flow rate: 300 versus 350 mL/min if the initial flow is greater than 400 mL/min. Outcome parameters should include effects on adequacy, manpower utilization, and cost of intervention.
Studies should culture the tips of all catheters removed for both CRB and fibrin sheath disruption to determine the frequency of occult “silent” infection.

Additional studies are required to define the agents and concentrations of antibiotic locks that can be used, including studies of systemic levels during prolonged periods.

Long-term studies are needed on antibiotic and antimicrobial resistance to antibiotic locks and ointments used to prevent infection.