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## Complete Summary

#### GUIDELINE TITLE

NKF-KDOQI clinical practice guidelines for vascular access: update 2006.

#### BIBLIOGRAPHIC SOURCE(S)

Vascular Access Work Group. Clinical practice guidelines for vascular
access. Am J Kidney Dis 2006 Jul;48 Suppl 1:S248-73.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16813991)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: NKF-K/DOQI clinical practice
guidelines for vascular access: update 2000. Am J Kidney Dis 2001
Jan;37(1 Suppl 1):S137-81.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

End-stage renal disease (ESRD)

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nephrology\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Clinical Laboratory Personnel\
Dietitians\
Health Care Providers\
Health Plans\
Nurses\
Patients\
Physician Assistants\
Physicians\
Social Workers

#### GUIDELINE OBJECTIVE(S)

To update the 2000 Kidney Disease Outcomes Quality Initiative (KDOQI)
Clinical Practice Guidelines on Vascular Access

#### TARGET POPULATION

Adult and pediatric patients with end-stage renal disease who receive
hemodialysis treatment

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Patient education on modalities of kidney replacement therapy (KRT)
    and monitoring of accesses

2.  Patient evaluation prior to placement of permanent hemodialysis (HD)
    access, including history and physical exam, duplex ultrasound, and
    central vein evaluation

3.  Structured approach to selection of the type of hemodialysis access
    (fistula, graft, or peritoneal dialysis catheter)

4.  Structured approach to selection of the location of hemodialysis
    access

    -   Fistula: wrist, elbow, or transposed brachial basilica vein

    -   Arteriovenous graft (AVG): forearm loop, upper arm, chest wall

    -   Catheters and port catheter systems: right internal jugular vein
        or secondary locations

5.  Placement of functional permanent access prior to initiation of
    dialysis therapy

6.  Use of aseptic technique and appropriate cannulation methods of
    fistulae and grafts

7.  Optimal timing of fistula and graft cannulation

8.  Monitoring of fistula maturation

9.  Use of infection control measures for all HD catheters

10. An organized monitoring/surveillance approach to detect access
    dysfunction

    -   Physical examination

    -   Surveillance of grafts and fistulae

    -   Referral for evaluation (diagnostic) and treatment

11. Timely evaluation and treatment of fistula complications

    -   Assessment of persistent swelling, delays in maturation,
        inadequate blood flow, venous stenosis, thrombosis, aneurysm,
        ischemia, infection

    -   Treatment of stenosis with percutaneous angioplasty (PTA) or
        surgical revision

    -   Treatment of thrombosis with thrombectomy

    -   Referral of patients with an arteriovenous fistula (AVF) with
        ischemia to a vascular access surgeon

    -   Treatment of infections with antibiotics and, for extensive
        infection, resection of the infected graft material

12. Management and treatment of AVG complications

    -   Assessment of extremity edema, risks for graft rupture, severe
        degenerative changes, pseudoaneurysm, stenosis, thrombosis,
        infection

    -   Treatment of AVGs with severe degenerative changes or
        pseudoaneurysm with revision/repair

    -   Treatment of stenosis without thrombosis with angioplasty or
        surgical revision

    -   Treatment of thrombosis and associated stenosis with
        percutaneous thrombectomy with angioplasty or surgical
        thrombectomy with AVG revision

    -   Treatment of infection with antibiotics, and for extensive
        infection, resection of the infected graft material

13. Evaluation of dysfunctional catheters and ports to facilitate
    prevention and early treatment

    -   Treatment of dysfunctional catheters and ports with
        repositioning, thrombolytics, or catheter exchange with sheath
        disruption

    -   Treatment infected HD catheter or port with antibiotic(s)

14. Use of continuous quality improvement (CQI) to monitor clinical
    outcome goals

#### MAJOR OUTCOMES CONSIDERED

-   Vascular access-related morbidity

-   Maturation and function of new arteriovenous fistula (AVF)

-   Change in approach to access placement

-   Infection rates

-   Infection clearing rates

-   Reinfection rates

-   Infection-free time

-   Access survival

-   Maintenance of access patency/function

-   Blood flow achieved

-   Sensitivity and specificity of tests for periodic monitoring of
    access

-   Re-establishment of patency/function in malfunctioning catheter

-   Hospitalization

-   Costs associated with the maintenance of access patency

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Based on the draft guideline statements, the Work Group members agreed
on topics that would be systematically reviewed and formulated questions
defining predictors, interventions, comparators, and outcomes of
interest. Search strategies were developed based on these questions and
topics, in addition to the study designs and years of publications of
interest to the Work Group (see Appendix 2 of the original guideline
document). Articles of interest were identified through MEDLINE searches
of English language literature of human studies in May through July
2004. Broad search terms were used to avoid missing potentially
pertinent articles. The searches were supplemented by articles
identified by Work Group members through June 2005.

Only full journal articles of original data were included. The searches
were limited to studies published since January 1997 since earlier
publications were reviewed in the previous Dialysis Outcomes Quality
Initiatives (DOQI) guidelines. Editorials, letters, abstracts, and
unpublished reports were not included. Selected review articles,
however, were included for background material. No systematic process
was followed to obtain review articles.

Abstracts and titles from the MEDLINE search results were prescreened by
members of the Evidence Review Team for general relevance. A second
round of screening was performed on the abstracts by Work Group members
for relevance using predefined eligibility criteria, described below.
Articles were retrieved by the Evidence Review Team and then rescreened
by Work Group members and/or the Evidence Review Team. Eligible studies
were extracted using standardized extraction forms. Domain experts made
the final decisions regarding the eligibility of all articles.

**Literature Yield**

A total of 2,892 citations were screened, of which 388 were review
articles. There were 112 articles (89 studies in adults, 13 in children,
10 review articles) that were potentially relevant. These articles were
retrieved for full review. Of these, 58 articles were accepted for full
data extraction by the Work Group members. Because of small sample
sizes, articles in children were not formally data extracted but
reviewed in detail by the 2 pediatric nephrologists on the Work Group
and used to write the narrative summary in the pediatric section.
Articles in adults were randomly assigned to individual Work Group
members for data extraction. Five additional articles were added by Work
Group experts and the Evidence Review Team. Finally, 24 studies answered
questions pertinent to topics chosen for systematic listing in Summary
Tables. See Table 4 of Appendix 1 in the original guideline document for
more details.

**Limitations of Approach**

While the literature searches were intended to be comprehensive, they
were not exhaustive. MEDLINE was the only database searched, and
searches were limited to English language publications. Hand searches of
journals were not performed, and review articles and textbook chapters
were not systematically searched. However, important studies known to
the domain experts that were missed by the literature search were
included in the review.

Because of resource limitations and other practical considerations,
there were several deviations from the original protocol for several of
the update topics. These primarily resulted in nephrologists in the
Evidence Review Team, rather than Work Group members, performing the
primary article screening and the data extraction for articles included
in several Summary Tables. However, all articles that met criteria for
all topics, all completed data extraction forms, and all Summary Tables
were distributed to relevant Work Group members for critical review and
incorporation into guidelines.

#### NUMBER OF SOURCE DOCUMENTS

24

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE 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.)

  ----------------------------------------------------------------------------------
  ** **               ** **        **Methodological                    
                                   Quality**                           
  ------------------- ------------ ------------------ ---------------- -------------
  **Outcome**         Population   Well designed and  Some problems in Poorly
                                   analyzed (little,  design and/or    designed
                                   if any, potential  analysis (some   and/or
                                   bias)              potential bias)  analyzed
                                                                       (large
                                                                       potential
                                                                       bias)

  Health outcome(s)   Target       Strong^a^          Moderately       Weak^h^
                      population                      Strong^b^        

  Health outcome(s)   Other than   Moderately         Moderately       Weak^h^
                      the target   Strong^c^          Strong^d^        
                      population                                       

  Surrogate measure   Target       Moderately         Weak^f^          Weak^h^
  for health          population   Strong^e^                           
  outcome(s)                                                           

  Surrogate measure   Other than   Weak^g^            Weak^g^          Weak^g,h^
  for health          the target                                       
  outcome(s)          population                                       

  **Definitions**:\                                                    
  \                                                                    
  **Strong**:                                                          
  ^a^Evidence                                                          
  includes results                                                     
  from well-designed,                                                  
  well-conducted                                                       
  study/studies in                                                     
  the target                                                           
  population that                                                      
  directly assess                                                      
  effects on health                                                    
  outcomes.\                                                           
  \                                                                    
  **Moderately                                                         
  Strong**:                                                            
  ^b^Evidence is                                                       
  sufficient to                                                        
  determine effects                                                    
  on health outcomes                                                   
  in the target                                                        
  population, but the                                                  
  strength of the                                                      
  evidence is limited                                                  
  by the number,                                                       
  quality, or                                                          
  consistency of the                                                   
  individual studies.                                                  
  ^c^OR evidence is                                                    
  from a population                                                    
  other than the                                                       
  target population,                                                   
  but from                                                             
  well-designed,                                                       
  well-conducted                                                       
  studies; ^d^OR                                                       
  evidence is from                                                     
  studies with some                                                    
  problems in design                                                   
  and/or analyses;                                                     
  ^e^OR evidence is                                                    
  from well-designed,                                                  
  well-conducted                                                       
  studies or                                                           
  surrogate endpoints                                                  
  for efficacy and/or                                                  
  safety in the                                                        
  target population.\                                                  
  \                                                                    
  **Weak**:                                                            
  ^f^Evidence is                                                       
  insufficient to                                                      
  assess the effects                                                   
  on net health                                                        
  outcomes because it                                                  
  is from studies                                                      
  with some problems                                                   
  in design and/or                                                     
  analysis on                                                          
  surrogate endpoints                                                  
  for efficacy and/or                                                  
  safety in the                                                        
  target population;                                                   
  ^g^OR the evidence                                                   
  is only for                                                          
  surrogate measures                                                   
  in a population                                                      
  other than the                                                       
  target population;                                                   
  ^h^OR the evidence                                                   
  is from studies                                                      
  that are poorly                                                      
  designed and/or                                                      
  analyzed.                                                            
  ----------------------------------------------------------------------------------

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Generation of Data Extraction Forms**

Data extraction forms were designed to capture information on various
aspects of the primary articles. Forms for all topics included study
setting and demographics, eligibility criteria, causes of kidney
disease, numbers of subjects, study design, study funding source,
dialysis characteristics, comorbid conditions, descriptions of relevant
risk factors or interventions, description of outcomes, statistical
methods, results, study quality (based on criteria appropriate for each
study design, study applicability, and sections for comments and
assessment of biases. Training of the Work Group members to extract data
from primary articles occurred by emails and teleconferences. Work Group
members were assigned the task of data extraction of articles.

**Generation of Evidence Tables**

The Evidence Review Team condensed the information from the data
extraction forms into evidence tables, which summarized individual
studies. These tables were created for the Work Group members to assist
them with review of the evidence and are not included in the guidelines.
All Work Group members received copies of all extracted articles and all
evidence tables. During the development of the evidence tables, the
Evidence Review Team checked the data extraction for accuracy and
re-screened the accepted articles to verify that each of them met the
initial screening criteria determined by the Work Group. If the criteria
were not met, the article was rejected, in consultation with the Work
Group.

**Format for Summary Tables**

Summary Tables describe the studies according to the following
dimensions: study size and follow-up duration, applicability or
generalizability, results, and methodological quality. Within each
table, the studies are first grouped by outcome type. Data entered into
Summary Tables were derived from the data extraction forms, evidence
tables, and/or the articles by the Evidence Review Team. All Summary
Tables were reviewed by the Work Group members.

Within each outcome, studies are ordered first by methodological quality
(best to worst), then by applicability (most to least), and then by
study size (largest to smallest). When relevant, outcome thresholds
(e.g., of access flow measurement) are included. Results are presented
by using the appropriate metric or summary symbols, as defined in the
table footnotes.

**Systematic Review Topics, Study Eligibility Criteria, and Studies
Evaluated**

The topics for each Update were selected by the respective Work Group
members for systematic review (see Table 1-3 in Appendix 1 of the
original guideline document). The eligibility criteria were defined by
the Work Group members in conjunction with the Evidence Review Team.

**Grading of Individual Studies**

*Study Size and Duration*

The study (sample) size is used as a measure of the weight of the
evidence. In general, large studies provide more precise estimates of
prevalence and associations. In addition, large studies are more likely
to be generalizable; however, large size alone, does not guarantee
applicability. A study that enrolled a large number of selected patients
may be less generalizable than several smaller studies that included a
broad spectrum of patient populations. Similarly, longer duration
studies may be of better quality and more applicable, depending on other
factors.

*Applicability*

Applicability (also known as generalizability or external validity)
addresses the issue of whether the study population is sufficiently
broad so that the results can be generalized to the population of
interest at large. The study population is typically defined primarily
by the inclusion and exclusion criteria. The target population was
defined to include patients with kidney failure, specifically those on
dialysis. A designation for applicability was assigned to each article,
according to a three-level scale. In making this assessment,
sociodemographic characteristics were considered, as well as comorbid
conditions and prior treatments. Applicability is graded in reference to
the population of interest as defined in the clinical question. For
example for the question of treatment of catheter-related infections the
reference population is that of HD patients with infected cuffed
tunneled hemodialysis (HD) catheters (see Appendix 1 of the original
guideline document for details).

*Results*

The type of results available in each study is determined by the study
design, the purpose of the study, and the question(s) being asked. The
Work Group decided on the eligibility criteria and outcomes of interest
(see Tables 1-3 in Appendix 1 of the original guideline document).

*Diagnostic Test Studies*

For studies of diagnostic tests, sensitivity and specificity data or
area under the curve were included when reported. When necessary,
sensitivity and specificity data were calculated from the reported data.
Diagnostic tests were evaluated according to a hierarchy of diagnostic
tests. Each test was assessed according to diagnostic technical
capacity, accuracy, diagnostic and therapeutic impact, and patient
outcome. This ultimately affected the overall strength of a
recommendation regarding a diagnostic test.

*Methodological Quality*

Methodological quality (or internal validity) refers to the design,
conduct, and reporting of the clinical study. Because studies with a
variety of types of design were evaluated, a 3-level classification of
study quality was devised (see Appendix 1 of the  original guideline
document for details).

**Summarizing Reviews and Selected Original Articles**

Work Group members had wide latitude in summarizing reviews and selected
original articles for topics that were determined not to require a
systemic review of the literature.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Work Group sought to update the guidelines using an evidence-based
approach. After topics and relevant clinical questions were identified
for the updates, the available scientific literature on those topics was
systematically searched and summarized.

**[Creation of Groups]{.underline}**

The Kidney Disease Outcomes Quality Initiative (KDOQI) Advisory Board
selected the Work Group Chairs and the Director of the Evidence Review
Team then assembled groups to be responsible for the development of the
updates. These Work Groups and the Evidence Review Team collaborated
closely throughout the project.

The Work Groups consisted of domain experts, including individuals with
expertise in nephrology, surgery, radiology, pediatrics, nursing and
nutrition. For each guideline update, the first task of the Work Group
members was to define the overall topics and goals of the updates. They
then further developed and refined each topic, literature search
strategies, and data extraction forms. The Work Group members were the
principal reviewers of the literature, and from their reviews and
detailed data extractions, they summarized the available evidence and
took the primary roles of writing the guidelines and rationale
statements. Completed data extractions were posted on a National Kidney
Foundation (NKF) website for direct access by Work Group members.

The Evidence Review Team consisted of nephrologists (one senior
nephrologist and two nephrology fellows), methodologists, and research
assistants from Tufts-New England Medical Center with expertise in
systematic review of the medical literature. They instructed the Work
Group members in all steps of systematic review and critical literature
appraisal. The Evidence Review Team also coordinated the methodological
and analytical process of the report, defined and standardized the
methodology of performing literature searches, of data extraction, and
of summarizing the evidence in summary tables. They organized abstract
and article screening, created forms to extract relevant data from
articles, organized Work Group member data extraction, and tabulated
results. Throughout the project the Evidence Review Team led discussions
on systematic review, literature searches, data extraction, assessment
of quality and applicability of articles, evidence synthesis, and
grading of the quality of the body of evidence and the strength of
guideline recommendations.

**[Refinement of Update Topics and Development of
Materials]{.underline}**

The Work Group reviewed the 1995 DOQI Clinical Practice Guidelines and
the 2000 KDOQI updates and decided which of the guideline
recommendations required updates and which should remain unchanged.
These assessments were based primarily on expert opinion regarding the
currency of the previous guidelines and the likelihood of availability
of new evidence. Preliminary literature searches were made to inform
this process. To allow for timely review, it was determined that each
set of guidelines would be able to have systematic reviews on only a
limited number of topics. After literature review, the experts decided
which recommendations would be supported by evidence or by opinion.

The Work Groups and Evidence Review Team developed: a) draft guideline
statements; b) draft rationale statements that summarized the expected
pertinent evidence; and c) data extraction forms containing the data
elements to be retrieved from the primary articles. The topic refinement
process began prior to literature retrieval and continued through the
process of reviewing individual articles. Recommendations based on
adequate evidence were categorized as Guidelines (CPGs), while
opinion-based statements were categorized as Clinical Practice
Recommendations (CPRs).

The Work Groups and Evidence Review Team developed: a) draft guideline
statements; b) draft rationale statements that summarized the expected
pertinent evidence; and c) data extraction forms containing the data
elements to be retrieved from the primary articles. The topic refinement
process began prior to literature retrieval and continued through the
process of reviewing individual articles. Recommendations based on
adequate evidence were categorized as Guidelines (CPGs), while
opinion-based statements were categorized as Clinical Practice
Recommendations (CPRs).

**Rating the Strength of Recommendations**

After literature review, the experts decided which recommendations were
supported by evidence and which were supported by consensus of Work
Group opinion. Evidence-based guideline recommendations were graded as
strong (A) or moderate (B). Recommendations based on weak evidence (C)
and/or consensus of expert opinion were labeled as Clinical Practice
Recommendations (CPRs). See \"Rating Scheme for the Strength of the
Recommendations\" below.

#### RATING SCHEME FOR THE STRENGTH OF THE 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.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

As was the case with the initial Guidelines, the current guideline
updates were subjected to a three-stage review process. They were
presented first to the National Kidney Foundation Dialysis Outcomes
Quality Initiative (NKF-DOQI) Steering Committee and revised in response
to the comments received. In the second stage, the Kidney Disease
Outcomes Quality Initiative (K/DOQI) Advisory Board, along with other
experts in the field, provided comments. After considering these, the
Work Groups produced a third draft of the guidelines. In the final
stage, this draft was made available for public review and comment by
all interested parties, including End-Stage Renal Disease (ESRD)
Networks, professional and patient associations, dialysis providers,
government agencies, product manufacturers, managed care groups, and
individuals. The comments received were reviewed and, where appropriate,
incorporated in the final version of the updated guideline.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the strength of each guideline or recommendation (A, B,
or CPR), based on the quality of the supporting evidence as well as
additional considerations, are provided at the end of the \"Major
Recommendations\" field.

**[Clinical Practice Guidelines for Vascular Access]{.underline}**

**Guideline 1. Patient Preparation for Permanent Hemodialysis Access**

Appropriate planning allows for the initiation of dialysis therapy at
the appropriate time with a permanent access in place at the start of
dialysis therapy.

1.1 Patients with a glomerular filtration rate (GFR) less than 30
mL/min/1.73 m^2^ (chronic kidney disease \[CKD\] stage 4) should 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 placement of a permanent dialysis access, if
necessary. **\[A\]**

1.2 In patients with CKD stage 4 or 5, forearm and upper-arm veins
suitable for placement of vascular access should not be used for
venipuncture or for the placement of intravenous (IV) catheters,
subclavian catheters, or peripherally inserted central catheter lines
(PICCs). **\[B\]**

1.3 Patients should have a functional permanent access at the initiation
of dialysis therapy.

1.3.1 A fistula should be placed at least 6 months before the
anticipated start of hemodialysis (HD) treatments. This timing allows
for access evaluation and additional time for revision to ensure a
working fistula is available at initiation of dialysis therapy.
**\[B\]**

1.3.2 A graft should, in most cases, be placed at least 3 to 6 weeks
before the anticipated start of HD therapy. Some newer graft materials
may be cannulated immediately after placement. **\[B\]**

1.3.3 A peritoneal dialysis (PD) catheter ideally should be placed at
least 2 weeks before the anticipated start of dialysis treatments. A
backup HD access does not need to be placed in most patients. A PD
catheter may be used as a bridge for a fistula in \"appropriate\"
patients. **\[B\]**

1.4 Evaluations that should be performed before placement of a permanent
HD access include (see table below):

1.4.1 History and physical examination. **\[B\]**

1.4.2 Duplex ultrasound of the upper-extremity arteries and veins,
**\[B\]**

1.4.3 Central vein evaluation in the appropriate patient known to have a
previous catheter or pacemaker. **\[A\]**

**Patient Evaluation Prior to Access Placement**

  -----------------------------------------------------------------------
  **Consideration**               **Relevance**
  ------------------------------- ---------------------------------------
  **Patient History**             

  History of previous CVC         Previous placement of a CVC is
                                  associated with central venous
                                  stenosis.

  Dominant arm                    To minimize negative impact on quality
                                  of life, use of the nondominant arm is
                                  preferred.

  History of pacemaker use        There is a correlation between
                                  pacemaker use and central venous
                                  stenosis.

  History of severe CHF           Accesses may alter hemodynamics and
                                  cardiac output.

  History of arterial or venous   Previous placement of an arterial or
  peripheral catheter             venous peripheral catheter may have
                                  damaged target vasculature.

  History of diabetes mellitus    Diabetes mellitus is associated with
                                  damage to vasculature necessary for
                                  internal accesses.

  History of anticoagulant        Abnormal coagulation may cause clotting
  therapy or any coagulation      or problems with hemostasis of
  disorder                        accesses.

  Presence of comorbid            Morbidity associated with placement and
  conditions, such as malignancy  maintenance of certain accesses may not
  or coronary artery disease,     justify their use in some patients.
  that limit patient\'s life      
  expectancy                      

  History of vascular access      Previously failed vascular accesses
                                  will limit available sites for
                                  accesses; the cause of a previous
                                  failure may influence planned access if
                                  the cause is still present.

  History of heart valve disease  Rate of infection associated with
  or prosthesis                   specific access types should be
                                  considered.

  History of previous arm, neck,  Vascular damage associated with
  or chest surgery/trauma         previous surgery or trauma may limit
                                  viable access sites.

  Anticipated kidney transplant   Catheter access may be sufficient.
  form living donor               

  **Physical Examination**        

  *Physical Examination of        
  Arterial System*                

  Character of peripheral pulses, An adequate arterial system is needed
  supplemented by hand-held       for access; the quality of the arterial
  Doppler evaluation when         system will influence the choice of
  indicated                       access site.

  Results of Allen test           Abnormal arterial flow pattern to the
                                  hand may contraindicate the creation of
                                  a radial-cephalic fistula.

  Bilateral upper extremity blood Pressures determine suitability of
  pressures                       arterial access in upper extremities.

  *Physical Examination of the    
  Venous System*                  

  Evaluation for edema            Edema indicates venous outflow problems
                                  that may limit usefulness of the
                                  associated potential access site or
                                  extremity for access placement.

  Assessment of arm size          Differential arm size may indicate
  comparability                   inadequate veins or venous obstruction
                                  which should influence choice of access
                                  site.

  Examination for collateral      Collateral veins are indicative of
  veins                           venous obstruction.

  Tourniquet venous palpitation   Palpitation and mapping allow selection
  with vein mapping               of ideal veins for access.

  Examination for evidence of     Use of CVCs is associated with central
  previous central or peripheral  venous stenosis; previous placement of
  venous catheterization          venous catheters may have damaged
                                  target vasculature necessary for
                                  access.

  Examination for evidence of     Vascular damage associated with
  arm, chest, or neck             previous surgery or trauma may limit
  surgery/trauma                  access sites.

  *Cardiovascular Evaluation*     

  Examination for evidence of     Accesses may alter cardiac output.
  heart failure                   
  -----------------------------------------------------------------------

Definitions: CVC, central venous catheter; CHF, congestive heart failure

**Guideline 2. Selection and Placement of Hemodialysis Access**

A structured approach to the type and location of long-term HD accesses
should help optimize access survival and minimize complications.

The access should be placed distally and in the upper extremities
whenever possible. Options for fistula placement should be considered
first, followed by prosthetic grafts if fistula placement is not
possible. Catheters should be avoided for HD and used only when other
options listed are not available.

2.1 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):

2.1.1 Preferred: Fistulae. **\[B\]**

2.1.1.1 A wrist (radiocephalic) primary fistula. **\[A\]**

2.1.1.2 An elbow (brachiocephalic) primary fistula. **\[A\]**

2.1.1.3 A transposed brachial basilic vein fistula: **\[B\]**

2.1.2 Acceptable: Arteriovenous graft (AVG) of synthetic or biological
material, such as: **\[B\]**

2.1.2.1 A forearm loop graft, preferable to a straight configuration.

2.1.2.2 Upper-arm graft.

2.1.2.3 Chest wall or \"necklace\" prosthetic graft or lower-extremity
fistula or graft; all upper-arm sites should be exhausted.

2.1.3 Avoid if possible: Long-term catheters. **\[B\]**

2.1.3.1 Short-term catheters should be used for acute dialysis and for a
limited duration in hospitalized patients. Noncuffed femoral catheters
should be used in bed-bound patients only. **\[B\]**

2.1.3.2 Long-term catheters or dialysis port catheter systems should be
used in conjunction with a plan for permanent access. Catheters capable
of rapid flow rates are preferred. Catheter choice should be based on
local experience, goals for use, and cost. **\[B\]**

2.1.3.3 Long-term catheters should not be placed on the same side as a
maturing arteriovenous (AV) access, if possible. **\[B\]**\
*Special attention should be paid to consideration of avoiding femoral
catheter access in HD patients who are current or future kidney
transplant candidates. Magnetic resonance angioplasty (MRA) imaging of
both arteries and veins is the diagnostic procedure of choice for
evaluating central vessels for possible chest wall construction.*

2.1.4 Patients should be considered for construction of a primary
fistula after failure of every dialysis AV access. **\[B\]**

2.1.5 While this order of access preference is similar for pediatric
patients, special considerations exist that should guide the choice of
access for children receiving HD. Please refer to Clinical Practice
Recommendation (CPR) 8 for specific recommendations.

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](http://www.guideline.gov/summary/summary.aspx?doc_id=10016&nbr=005330)),
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**

+-----------------------------------------------------------------------+
| -   Locate, inspect, and palpate the needle cannulation sites prior   |
|     to skin preparation. Repeat prep if the skin is touched by the    |
|     patient or staff once the skin prep has been applied, but the     |
|     cannulation not completed.                                        |
|                                                                       |
| -   Wash access site using an antibacterial soap or scrub and water.  |
|                                                                       |
| -   Cleanse the skin by applying 2% chlorhexidine gluconate/70%       |
|     isopropyl alcohol or 70% alcohol and/or 10% povidone iodine as    |
|     per manufacturer\'s instructions for use.                         |
|                                                                       |
| *Notes:*                                                              |
|                                                                       |
| -   2% chlorhexidine gluconate/70% isopropyl alcohol antiseptic has a |
|     rapid (30 s) and persistent (up to 48 hr) antimicrobial activity  |
|     on the skin. Apply solution using back and forth friction scrub   |
|     for 30 seconds. Allow area to dry. Do not blot the solution.      |
|                                                                       |
| -   Alcohol has a short bacteriostatic action time and should be      |
|     applied in a rubbing motion for 1 minute immediately prior to     |
|     needle cannulation.                                               |
|                                                                       |
| -   Povidone iodine needs to be applied for 2-3 minutes for its full  |
|     bacteriostatic action to take effect and must be allowed to dry   |
|     prior to needle cannulation.                                      |
|                                                                       |
| -   Clean gloves should be worn by the dialysis staff for             |
|     cannulation. Gloves should be changed if contaminated at any time |
|     during the cannulation procedure.                                 |
|                                                                       |
| -   New, clean gloves should be worn by the dialysis staff for each   |
|     patient with proper infection control measures followed between   |
|     each patient.                                                     |
+-----------------------------------------------------------------------+

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**

+--------------------------------------+-------------------------------+
| **Technique**                        | **Rationale**                 |
+======================================+===============================+
| After skin preparation, apply a      | Compresses peripheral nerve   |
| tourniquet to increase the venous    | endings between epidermis and |
| pressure, and pull skin taut in      | dermis.\                      |
| opposite direction of needle         | Increases surface tension     |
| insertion. Avoid excessive pressure  | thereby facilitating smoother |
| to the cannulation site to prevent   | incision of skin with less    |
| flattening of the vessel. Stabilize  | surface area contacting       |
| but do not obliterate the vessel.    | cutting edge of needle.\      |
|                                      | Enables better stabilization  |
|                                      | of graft or vessel to be      |
|                                      | cannulated.                   |
+--------------------------------------+-------------------------------+
| For easily palpated vessel, use      | Less steep angles increase    |
| approximately 25 degree angle with   | risk of dragging cutting edge |
| the bevel up. Arterial needle        | of needle along surface of    |
| placement can be in antegrade (up or | vessel. Steeper angles        |
| in the direction of the blood flow)  | increase risk of perforating  |
| or retrograde (down or against the   | underside (backwall) of       |
| direction of blood flow). The venous | vessel.\                      |
| needle should always be in the same  | \                             |
| direction as the blood flow.         | Needle direction of the       |
|                                      | venous needle in the same     |
|                                      | direction as the blood flow   |
|                                      | will prevent excessive        |
|                                      | pressure at the needle site.  |
|                                      | The arterial needle in either |
|                                      | direction will not increase   |
|                                      | the risk of recirculation as  |
|                                      | long as the access blood flow |
|                                      | is greater to the blood pump  |
|                                      | setting.                      |
+--------------------------------------+-------------------------------+
| Once the vessel has been penetrated: | Any manipulation may          |
|                                      | traumatize the intima of the  |
| -   Advance the needle slowly with   | vessel. The use of a blackeye |
|     cutting edge facing top of       | needle will eliminate the     |
|     vessel and do not rotate axis.   | need to rotate the needle due |
|                                      | to poor flows.                |
+--------------------------------------+-------------------------------+
| -   Tape the needle at the same      | Pressing the needle shaft     |
|     angle or one similar to the      | flat against the skin moves   |
|     angle of insertion.              | the needle tip from the       |
|                                      | desired position within the   |
|                                      | vessel lumen.                 |
+--------------------------------------+-------------------------------+
| -   Remove needle at same or angle   | Avoid trauma to any intima by |
|     similar to angle of insertion,   | dragging cutting edge along   |
|     and NEVER APPLY PRESSURE BEFORE  | it. Avoid pressing cutting    |
|     NEEDLE IS COMPLETELY OUT.        | edge into intima when         |
|                                      | applying pressure for HD.     |
+--------------------------------------+-------------------------------+

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**

+-----------------------------+----------------------------------------+
| **Technique**               | **Rationale**                          |
+=============================+========================================+
| After skin preparation,     | Compress peripheral nerve endings      |
| pull skin taut in opposite  | between epidermis and dermis.\         |
| direction of needle         | Facilitates smoother incision of skin  |
| insertion. Avoid excessive  | with less surface area contacting      |
| pressure to the cannulation | cutting edge of needle.\               |
| site to stabilize and       | Enables better stabilization of graft  |
| prevent flattening of the   | or vessel to be cannulated.            |
| graft material.             |                                        |
+-----------------------------+----------------------------------------+
| Use approximately 45 degree | Less steep angles increase risk of     |
| angle of insertion.         | dragging cutting edge of needle along  |
|                             | surface of vessel. Steeper angles      |
|                             | increase risk of perforating underside |
|                             | of vessel.                             |
+-----------------------------+----------------------------------------+
| Once the vessel has been    |                                        |
| penetrated, there are       |                                        |
| basically 2 methods         |                                        |
| employed in current         |                                        |
| practice:                   |                                        |
+-----------------------------+----------------------------------------+
| a.  Advance the needle      | a.  Any manipulation may traumatize    |
|     slowly with cutting     |     the intima of the vessel. This is  |
|     edge facing top of      |     the preferred method for routine   |
|     vessel and do not       |     AVG cannulation technique.         |
|     rotate axis             |                                        |
+-----------------------------+----------------------------------------+
| b.  For a deep, hard to     | b.  Rotating the axis avoids           |
|     palpate AVG immediately |     traumatizing the top of the intima |
|     rotate the axis of the  |     and prevents the tip of the needle |
|     needle 180 degrees and  |     from entering the backside of the  |
|     advance slowly with     |     graft material. This should only   |
|     bevel cutting edge      |     be utilized when the graft         |
|     facing bottom of the    |     backwall location is difficult to  |
|     vessel.                 |     determine and the risk of          |
|                             |     continuing the needle advancement  |
|                             |     into the backwall is high.         |
+-----------------------------+----------------------------------------+
| Tape needle at the same     | Pressing the needle shaft flat against |
| angle or one similar to the | the skin moves the needle tip from the |
| angle of insertion.         | desired position within the vessel     |
|                             | lumen.                                 |
+-----------------------------+----------------------------------------+
| Remove needle at same or    | Avoid trauma to any intima by dragging |
| angle similar to angle of   | cutting edge along it. Avoid pressing  |
| insertion, and NEVER APPLY  | cutting edge into intima when applying |
| PRESSURE BEFORE NEEDLE IS   | pressure for HD.                       |
| COMPLETELY OUT.             |                                        |
+-----------------------------+----------------------------------------+

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**

  -----------------------------------------------------------------------------------
  **Exam\        **Fistula\          **AVG\           **Stenosis or   **Infection or
  Steps**        (Normal)**          (Normal)**       Poor Maturation Steal Syndrome
                                                      (Abnormal)**    (Abnormal)**
  -------------- ------------------- ---------------- --------------- ---------------
  ***Look***     Well developed main Uniform size     Fistula with    *Infection*:
                 venous outflow, not graft in a loop  poor            Redness,
                 irregular/dilated   or straight      maturation -    swelling,
                 areas or aneurysm   configuration.   multiple venous broken skin,
                 formations, areas   No irregular     outflow veins   drainage,
                 of straight vein    areas or         (accessory      induration.\
                 that can be used    aneurysm         veins), poorly  \
                 for cannulation.\   formations with  defined         *Steal
                 \                   organized site   cannulation     Syndrome*: Hand
                 Vessel partially    rotation used    areas.\         of the access
                 collapses when arm  for cannulation  \               limb may appear
                 is elevated above   sites.           *Fistula*:      discolored due
                 head.                                Stenosis can    to poor
                                                      occur in artery arterial blood
                                                      or any of the   flow to the
                                                      venous outflow  hand. Check
                                                      veins. Look for nail beds,
                                                      a narrowing of  fingers, and
                                                      the outflow     hand for skin
                                                      vein or         color changes.
                                                      aneurysm        
                                                      formations.\    
                                                      \               
                                                      *Fistula or     
                                                      Graft*: Dilated 
                                                      neck veins or   
                                                      small surface   
                                                      collateral      
                                                      veins in the    
                                                      arm or neck     
                                                      above the       
                                                      vascular        
                                                      access.         

  ***Listen***   Low pitch           Low pitch        High pitch      *Steal
  with a         continuous          continuous       discontinuous   Syndrome*:
  stethoscope    diastolic and       diastolic and    systolic only   Fistula may
                 systolic            systolic                         have a very
                                                                      strong bruit.

  ***Feel***     Thrill at the       Thrill strongest *Fistula*:      *Infection*:
  with your      arterial            at the arterial  Pulse at the    Warm to touch,
  finger tips    anastomosis and     anastomosis, but site of a       swelling\
                 throughout the      should be felt   stenotic        \
                 entire outflow vein over entire      lesion\         *Steal
                 that is easy to     graft and easy   Pulse has a     Syndrome*: Feel
                 compress            to compress      water-hammer    bilateral limbs
                                                      feel\           (hands and
                                                      \               fingers) and
                                                      *Graft*: Thrill compare for the
                                                      and/or pulse    access limb to
                                                      strong at the   be the same as
                                                      site of a       the nonaccess
                                                      stenotic        limb. Compare
                                                      lesion. Pulse   temperature,
                                                      has a           grip strength
                                                      water-hammer    and range of
                                                      feel. A graft   motion, and any
                                                      with a low      complaints of
                                                      intra-access    pain. If the
                                                      blood flow      access limb has
                                                      feels mushy.    any major
                                                      Local area of   differences
                                                      the graft that  than the
                                                      feels mushy or  nonaccess limb,
                                                      irregular in    consider steal
                                                      shape can be a  syndrome.
                                                      site of         
                                                      aneurysm        
                                                      formation.      
  -----------------------------------------------------------------------------------

Definitions: AVG: Arteriovenous graft

**Considerations for Accessing Catheters and Cleansing Catheter Exit
Sites**

+-----------------------------------------------------------------------+
| Prepare procedure site using dialysis precautions.                    |
+-----------------------------------------------------------------------+
| Conduct procedures using aseptic technique (correct hand-washing,     |
| masks for patient and staff, \"no-touch\" technique, and disposable   |
| clean gloves).                                                        |
+-----------------------------------------------------------------------+
| Chlorhexidine 2% with 70% alcohol is the preferred solution for       |
| cleansing of long-term catheter sites.^a^\                            |
| For patients with sensitivities to chlorhexidine 2% with 70% alcohol, |
| chlorhexidine aqueous^a^ may be used instead.\                        |
| For patients with sensitivities to chlorhexidine aqueous, povidone    |
| solution^b^ may be used.                                              |
+-----------------------------------------------------------------------+
| Skin cleansing should include the following steps:                    |
|                                                                       |
| -   Apply solution/swab in a circular motion working from catheter    |
|     exit site outwards.                                               |
|                                                                       |
| -   Cover an area 10 cm in diameter.                                  |
|                                                                       |
| -   Repeat this step twice. Do not rinse off or blot excess solution  |
|     from skin.                                                        |
|                                                                       |
| -   Allow solution to dry completely before applying dressing.        |
+-----------------------------------------------------------------------+
| To cleanse the connection between any CVC hub and cap use 2 swabs:    |
|                                                                       |
| -   Grasp connection with 1 swab.                                     |
|                                                                       |
| -   Use second swab to clean from catheter connection up catheter for |
|     10 cm.                                                            |
|                                                                       |
| -   Cleanse hub connection site and cap vigorously with the first     |
|     swab. Discard swab.                                               |
|                                                                       |
| -   Do not drop a connection site once it is cleaned.                 |
+-----------------------------------------------------------------------+
| To cleanse the section of the catheter that lies adjacent to the      |
| skin, gently swab the top and undersides of the catheter starting at  |
| the exit site and working outwards.                                   |
+-----------------------------------------------------------------------+

^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**

+-----------------------------------------------------------------------+
| -   Duplex Doppler Ultrasound (Quantitative color velocity imaging):  |
|     \[DDU\]                                                           |
|                                                                       |
| -   Magnetic Resonance Angiography: \[MRA\]                           |
|                                                                       |
| -   Variable Flow Doppler Ultrasound (Specs USA): \[VFDU\]            |
|                                                                       |
| -   Ultrasound dilution (Transonics): \[UDT\]                         |
|                                                                       |
| -   CritLine III (optodilution by ultrafiltration; HemaMetrics):      |
|     \[OABF\]                                                          |
|                                                                       |
| -   CritLine III direct transcutaneous (HemaMetrics): \[TQA\]         |
|                                                                       |
| -   Glucose pump infusion technique: \[GPT\]                          |
|                                                                       |
| -   Urea dilution: \[UreaD\]                                          |
|                                                                       |
| -   Differential conductivity (GAMBRO): \[HDM\]                       |
|                                                                       |
| -   In line dialysance (Fresenius): \[DD\]                            |
+-----------------------------------------------------------------------+

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**

+-----------------------------------------------------------------------+
| a.  Establish a baseline when the access has matured and shortly      |
|     after the access is first used. Trend analysis is more useful     |
|     than any single measurement.                                      |
|                                                                       |
| b.  Assure that the zero setting on the pressure transducers of the   |
|     dialysis delivery system being used has been calibrated to be     |
|     accurate within [+]{.underline}5 mm Hg.                           |
|                                                                       |
| c.  Measure the mean arterial blood pressure (MAP) in the arm         |
|     contralateral to the access.                                      |
|                                                                       |
| d.  Enter the appropriate output or display screen where venous and   |
|     arterial pressures can be visualized (this varies for each        |
|     dialysis delivery system). If a gauge is used to display the      |
|     pressures, the pressure can be read from the gauge.               |
|                                                                       |
| e.  Stop the blood pump and cross clamp the venous line just proximal |
|     to the venous drip chamber with a hemostat (this avoids having to |
|     stop ultrafiltration for the brief period needed for the          |
|     measurement). On the arterial line, no hemostat is needed since   |
|     the occlusive roller pump serves as a clamp.                      |
|                                                                       |
| f.  Wait 30 seconds until the venous pressure is stable, then record  |
|     the arterial and venous intra-access pressure (IAP) values. The   |
|     arterial segment pressure can only be obtained if a pre-pump drip |
|     chamber is available and the dialysis system is capable of        |
|     measuring absolute pressures greater than 40 mm Hg.               |
|                                                                       |
| g.  Unclamp the venous return line and restore the blood pump to its  |
|     previous value.                                                   |
|                                                                       |
| h.  Determine the height correction, (delta h) between the access and |
|     the drip chamber(s) either by direct measurement (A) or using a   |
|     formula (B) based on the difference in height between the top of  |
|     the drip chamber and the top of the arm rest of the dialysis      |
|     chair (delta). Both measurements need to be in cm. Height         |
|     corrections are not needed if the measurements in step 6 are done |
|     with access level with the drip chamber                           |
|                                                                       |
|     -   Measure the height from the venous or arterial needle to the  |
|         top of the blood in the venous drip chamber. The offset in Hg |
|         = height (cm) x 0.76                                          |
|                                                                       |
|     -   Use the formula, offset in mm Hg = 3.6 + 0.35 x delta.        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| i.  The same correction values can be used for both if the 2 drip     |
|     chambers are at the same height. If the drip chambers are not at  |
|     equal heights, the arterial and venous height offsets must be     |
|     determined individually. In a given patient with a given access   |
|     the height offsets need to be measured only once and then used    |
|     until the access location is altered by construction of a new     |
|     access.                                                           |
|                                                                       |
| j.  Calculate the normalized arterial and venous segment static IAP   |
|     ratio(s), P~IA~/MAP                                               |
|                                                                       |
| > Arterial ratio = (arterial IAP + arterial height correction)/MAP    |
| >                                                                     |
| > Venous ratio = (venous IAP + venous height correction)/MAP          |
| >                                                                     |
| > Where P~IA~ is intra-access pressure                                |
+-----------------------------------------------------------------------+

**Criteria for Intervention**

  ---------------------------------------------------------------------------------------------------------------
  **Access                                                                                                     
  Pressure                                                                                                     
  Ratio**                                                                                                      
  -------------- ---------------------- --------- ------------ -------------- --------- ---------------------- --
  **Degree of    **Graft**                                     **Fistula**                                     
  Stenosis**                                                                                                   

                 **Arterial Segment**   ** **     **Venous     **Arterial     ** **     **Venous Segment**     
                                                  Segment**    Segment**                                       

  \<50% of       0.35-0.74                        0.15-0.49    0.13-0.43                0.08-0.34              
  diameter                                                                                                     

  \>50% of                                                                                                     
  diameter                                                                                                     

  Venous outlet  \>0.75                 or        \>0.5        \>0.43         or        \>0.35                 

  Intra-access   [\>]{.underline}0.65   **and**   \<0.5        \>0.43         **and**   [\<]{.underline}0.35   

  Arterial       \<0.3                            Clinical     \<0.13 +                 Clinical findings      
  inflow                                          findings     clinical                                        
                                                               findings                                        
  ---------------------------------------------------------------------------------------------------------------

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**

  -----------------------------------------------------------------------
  Access flow measured by ultrasound dilution, conductance dilution,
  thermal dilution, Doppler or other technique should be performed
  monthly. The assessment of flow should be performed during the first
  1.5 hour of the treatment to eliminate error caused by decreases in
  cardiac output or blood pressure related to
  ultrafiltration/hypotension. The mean value of 2 separate
  determinations (within 10% of each other) performed at a single
  treatment should be considered the access flow.\
  \
  *Graft*\
  If access flow is \<600 in a graft, the patient should be referred for
  fistulogram.\
  If access flow 1,000 mL/min that has decreased by more than 25% over 4
  month, the patient should be referred for fistulogram.

  -----------------------------------------------------------------------

**Patient Education Basics**

+-----------------------------------------------------------------------+
| All patients should be taught how to:                                 |
|                                                                       |
| a.  Compress a bleeding access.                                       |
|                                                                       |
| b.  Wash skin over access with soap and water daily and before        |
|     hemodialysis (HD).                                                |
|                                                                       |
| c.  Recognize signs and symptoms of infection.                        |
|                                                                       |
| d.  Select proper methods for exercising fistula arm with some        |
|     resistance to venous flow.                                        |
|                                                                       |
| e.  Palpate for thrill/pulse daily and after any episodes of          |
|     hypertension, dizziness, or lightheadedness.                      |
|                                                                       |
| f.  Listen for bruit with ear opposite access if they cannot palpate  |
|     for any reason.                                                   |
|                                                                       |
| All patients should know how to:                                      |
|                                                                       |
| a.  Avoid carrying heavy items draped over the access arm or wearing  |
|     occlusive clothing.                                               |
|                                                                       |
| b.  Avoid sleeping on the access arm.                                 |
|                                                                       |
| c.  Insist that staff rotate cannulation sites each treatment.        |
|                                                                       |
| d.  Ensure that staff are using proper techniques in preparing skin   |
|     prior to cannulation and wearing masks for all access             |
|     connections.                                                      |
|                                                                       |
| e.  Report any signs and symptoms of infection or absence of          |
|     bruit/thrill to dialysis personnel immediately.                   |
+-----------------------------------------------------------------------+

**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**

  -------------- ------------------------------------------------------------
  Inspection     Examine for erythema, swelling, gangrene, change of size of
                 aneurysms over time.

  Palpitation    Feel for intravascular pressure along the veins; examine for
                 segmental differences in quality.\
                 Feel for elevated/low skin temperature; check the quality of
                 pulsation along arteries and veins.\
                 Check for pain caused by finger pressure.

  Auscultation   Check for the presence of typical low-frequency bruit with
                 systolic and diastolic components.\
                 Examine for abnormal high-frequency bruit produced by
                 turbulence due to a stenosis.
  -------------- ------------------------------------------------------------

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**

  -----------------------------------------------------------------------
  Blood pump flow rates \<300 mL/min\
  \
  Arterial pressure increases (\< -250 mm Hg)\
  \
  Venous pressure increases (\>250 mm Hg)\
  \
  Conductance decreases (\<1.2): the ratio of blood pump flow to the
  absolute value of prepump pressure\
  \
  URR progressively \<65% or (Kt/V \<1.2)\
  \
  Unable to aspirate blood freely (late manifestation)\
  \
  Frequent pressure alarms - not responsive to patient repositioning or
  catheter flushing\
  \
  **Trend analysis of changes in access flow is the best predictor of
  access patency and risk for thrombosis.**

  -----------------------------------------------------------------------

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**

  -----------------------------------------------------------------------
  Mechanical\
  \
  Kinks (angulation in tunnel)\
  \
  Misplaced sutures\
  \
  Catheter migration\
  \
  Drug precipitation (some antibody locks or IV IgG)\
  \
  Patient position\
  \
  Catheter integrity\
  \
  Holes\
  \
  Cracks

  -----------------------------------------------------------------------

Definitions: IV IgG, intravenous Immunoglobulin G

**Available Thrombolytics**

+-----------------------------------------------------------------------+
| Streptokinase                                                         |
|                                                                       |
| -   Highly antigenic                                                  |
|                                                                       |
| -   Low fibrin affinity                                               |
|                                                                       |
| Urokinase                                                             |
|                                                                       |
| -   Available for PE treatment                                        |
|                                                                       |
| -   No longer manufactured (11/2004)                                  |
|                                                                       |
| Reteplase                                                             |
|                                                                       |
| -   Used in treatment of AMI                                          |
|                                                                       |
| -   Must be aliquoted and frozen                                      |
|                                                                       |
| Ateplase, tPA                                                         |
|                                                                       |
| -   High fibrin specificity                                           |
|                                                                       |
| -   FDA approved                                                      |
|                                                                       |
| -   Available in single dose vials                                    |
|                                                                       |
| -   No antigenicity                                                   |
+-----------------------------------------------------------------------+

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]{.underline}**

**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**

  -----------------------------------------------------------------------
  **Patient Size (kg)**      **Catheter Options**
  -------------------------- --------------------------------------------
  \<10 kg                    Made on a case by case basis

  10-20 kg                   8 French dual lumen

  20-25 kg                   7 French twin catheter

  20-40 kg                   10 French dual lumen\
                             10 French split catheter\
                             10 French twin catheter

  \>40 kg                    10 French twin catheter\
                             11.5 or 12.5 French dual lumen
  -----------------------------------------------------------------------

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]{.underline}**:

**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.)

  ----------------------------------------------------------------------------------
  ** **               ** **        **Methodological                    
                                   Quality**                           
  ------------------- ------------ ------------------ ---------------- -------------
  **Outcome**         Population   Well designed and  Some problems in Poorly
                                   analyzed (little,  design and/or    designed
                                   if any, potential  analysis (some   and/or
                                   bias)              potential bias)  analyzed
                                                                       (large
                                                                       potential
                                                                       bias)

  Health outcome(s)   Target       Strong^a^          Moderately       Weak^h^
                      population                      Strong^b^        

  Health outcome(s)   Other than   Moderately         Moderately       Weak^h^
                      the target   Strong^c^          Strong^d^        
                      population                                       

  Surrogate measure   Target       Moderately         Weak^f^          Weak^h^
  for health          population   Strong^e^                           
  outcome(s)                                                           

  Surrogate measure   Other than   Weak^g^            Weak^g^          Weak^g,h^
  for health          the target                                       
  outcome(s)          population                                       

  **Definitions**:\                                                    
  \                                                                    
  **Strong**:                                                          
  ^a^Evidence                                                          
  includes results                                                     
  from well-designed,                                                  
  well-conducted                                                       
  study/studies in                                                     
  the target                                                           
  population that                                                      
  directly assess                                                      
  effects on health                                                    
  outcomes.\                                                           
  \                                                                    
  **Moderately                                                         
  Strong**:                                                            
  ^b^Evidence is                                                       
  sufficient to                                                        
  determine effects                                                    
  on health outcomes                                                   
  in the target                                                        
  population, but the                                                  
  strength of the                                                      
  evidence is limited                                                  
  by the number,                                                       
  quality, or                                                          
  consistency of the                                                   
  individual studies.                                                  
  ^c^OR evidence is                                                    
  from a population                                                    
  other than the                                                       
  target population,                                                   
  but from                                                             
  well-designed,                                                       
  well-conducted                                                       
  studies; ^d^OR                                                       
  evidence is from                                                     
  studies with some                                                    
  problems in design                                                   
  and/or analyses;                                                     
  ^e^OR evidence is                                                    
  from well-designed,                                                  
  well-conducted                                                       
  studies or                                                           
  surrogate endpoints                                                  
  for efficacy and/or                                                  
  safety in the                                                        
  target population.\                                                  
  \                                                                    
  **Weak**:                                                            
  ^f^Evidence is                                                       
  insufficient to                                                      
  assess the effects                                                   
  on net health                                                        
  outcomes because it                                                  
  is from studies                                                      
  with some problems                                                   
  in design and/or                                                     
  analysis on                                                          
  surrogate endpoints                                                  
  for efficacy and/or                                                  
  safety in the                                                        
  target population;                                                   
  ^g^OR the evidence                                                   
  is only for                                                          
  surrogate measures                                                   
  in a population                                                      
  other than the                                                       
  target population;                                                   
  ^h^OR the evidence                                                   
  is from studies                                                      
  that are poorly                                                      
  designed and/or                                                      
  analyzed.                                                            
  ----------------------------------------------------------------------------------

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document, \"Pediatric
progress from chronic kidney disease (CKD) stages 1 to 5 and kidney
replacement therapy (KRT)/access.\"

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Early identification of patients with progressive renal failure for
    identification and protection of potential access sites

-   Reduced morbidity related to vascular access

-   Enhanced long-term access function

-   Reduced infection rates

-   Improved infection clearing rates

-   Reduced rates of hospitalization

-   Reduced costs associated with the maintenance of access patency

-   Early detection and treatment of access dysfunction

#### POTENTIAL HARMS

Complications of vascular access placement and maintenance (for example,
infection, stenosis, thrombosis, aneurysm, and limb ischemia).

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These Clinical Practice Guidelines (CPGs) and Clinical Practice
    Recommendations (CPRs) are based upon the best information available
    at the time of publication. They are designed to provide information
    and assist decision making. They are not intended to define a
    standard of care, and should not be construed one. Neither should
    they be interpreted as prescribing an exclusive course of
    management.

-   Variations in practice will inevitably and appropriately occur when
    clinicians take into account the needs of individual patients,
    available resources, and limitations unique to an institution or
    type of practice. (See \"Limitations\" sections in the original
    guideline document for a more detailed explanation specific to each
    guideline.) Every healthcare professional making use of these CPGs
    and CPRs is responsible for evaluating the appropriateness of
    applying them in the setting of any particular clinical situation.
    The recommendations for research contained within this document are
    general and do not imply a specific protocol.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation is an integral component of the Kidney Disease Outcomes
Quality Initiative process, and accounts for the success of its past
guidelines. The Kidney Learning System (KLS) component of the National
Kidney Foundation is developing implementation tools that will be
essential to the success of these guidelines.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Foreign Language Translations\
Patient Resources\
Pocket Guide/Reference Cards\
Quick Reference Guides/Physician Guides\
Resources\
Wall Poster

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Vascular Access Work Group. Clinical practice guidelines for vascular
access. Am J Kidney Dis 2006 Jul;48 Suppl 1:S248-73.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16813991)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1997 (updated 2006 Jul)

#### GUIDELINE DEVELOPER(S)

National Kidney Foundation - Disease Specific Society

#### SOURCE(S) OF FUNDING

Support for the development of these guidelines was provided by Amgen,
Inc., Baxter Healthcare Corp., Fresenius USA, Inc., Genentec, Inc., and
Watson Pharmaceuticals, Inc.

#### GUIDELINE COMMITTEE

NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality
Initiative) Vascular Adequacy Work Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Work Group Members*: Anatole Besarab, MD (*Co-Chair*) Henry Ford
Hospital, Detroit, MI;  Jack Work, MD (*Co-Chair*) Emory University
School of Medicine, Atlanta, GA; Deborah Brouwer, RN, CNN, McMurray, PA;
Timothy E. Bunchman, MD, DeVos Children\'s Hospital, Grand Rapids, MI;
Lesley C. Dinwiddie, MSN, RN, FNP, CNN, American Nephrology Nurses
Association, Cary, NC; Stuart L. Goldstein, MD, Texas Children\'s
Hospital, Houston, TX; Mitchell L. Henry, MD, Ohio State University,
Dublin, OH; Klaus Konner, MD, Medical University of Cologne, Cologne
General Hospital Merheim Medical Center, Cologne, Germany; Alan Lumsden,
MD, FACS, Baylor College of Medicine, Houston, TX; Thomas M. Vesely, MD,
Mallinckrodt Institute of Radiology, St Louis, MO

*Evidence Review Team*: Ethan Balk, MD, MPH, Project Director,
Hemodialysis and Peritoneal Dialysis Adequacy; Katrin Uhlig, MD, Project
Director, Vascular Access; George Fares, MD, Assistant Project Director,
Hemodialysis and Peritoneal Dialysis Adequacy; Ashish Mahajan, MD, MPH,
Assistant Project Director, Vascular Access, Hemodialysis and Peritoneal
Dialysis Adequacy; Amy Earley, BS; Rebecca Persson, BA; Gowri Raman, MD;
Christina Kwack Yuhan, MD; Priscilla Chew, MPH; Stanley Ip, MD; Mei
Chung, MPH

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The National Kidney Foundation makes every effort to avoid any actual or
potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a
member of the Work Group.

Specifically, all members of the Work Group are required to complete,
sign, and submit a Disclosure Questionnaire showing all such
relationships that might be perceived as real or potential conflicts of
interest. All affiliations are published in their entirety at the end of
this publication in the Biographical Sketch section of the Work Group
members.

-   Dr. Besarab has received research funds, grants or contracts from
    Abbott Laboratories, Advanced Magnetics, Affymaz, American Regent
    Inc. Amgen, Inc., Baxter, Genentech, Hoffman-La Roche, Rockwell
    International, Transonic Systems Inc., VascAlert, and Watson
    Pharmaceuticals.

-   Ms. Brouwer has received research funds, grants or contracts from CR
    Bard, Genentech, Transonic Systems Inc., and WL Gore.

-   Dr. Bunchman has received grants from Gambro Healthcare, Baxter
    Healthcare, and Dialysis Solution, Inc. He has received research
    funds, grants or contracts from Baxter, Dialysis Solutions Inc.,
    Gambro, Hoffman-La Roche, Johnson & Johnson, and Novartis.

-   Ms. Dinwiddie has received grants from ANNA. Genentech (and their
    medical education associates), Shire (including Cardinal MES and
    ProActive), American Regent, Ahrens, Balwit and Associates, Arrow,
    and Vasca. She has also received research funds, grants or contracts
    from Amgen, Arrow International, Genentech, Roche Canada, and Shire
    US.

-   Dr. Goldstein has received grants from Gambro Renal Products;
    Dialysis Solutions, Inc; Baxter Healthcare; B. Braun, Inc; Amgen
    Inc; Abbott Laboratories; and Toray Inc. He also has lectured for
    Genentech. He has received research funds, grants or contracts from
    the American Academy of Pediatrics, Baxter Healthcare, Dialysis
    Solutions, Inc., Gambro Renal Products, Genentech, Luitopold
    Pharmaceuticals, NxStage Inc., and the University of Missouri.

-   Dr. Henry has received grants from Novartis and MedImmune. He has
    received research funds, grants or contracts from
    Coalescent/Medtronic, Genzyme, Novartis, Hoffman-La Roche, and
    Wyeth.

-   Dr. Konner has received research funds, grants or contracts from
    Gambro Renal Products, Germany.

-   Dr. Lumsden has performed clinical trials for VNUS, Medtronic,
    Boston Scientific, and WL Gore. He has received research funds,
    grants or contracts from Boston Scientific, Medtronic, WL Gore, and
    VNUS.

-   Dr. Vesely has received grants from CR Bard; Angiodynamics, Inc;
    Spire BioMedical; Transonic, Inc; Bayer; Datascope; and Enpath. He
    has received research funds, grants or contracts from Angiodynamics,
    Bayer, CR Bard, Datascope, Enpath Medical Inc., Pervasis
    Therapeutics Inc., Spire Biomedical Inc., Rex Medical, Transonic
    Inc., and WL Gore.

-   Dr. Work has received research funds, grants or contracts from
    Cleveland Clinic, National Kidney Foundation\'s Clinical Meeting,
    Novoste Corporation, the University of Missouri Dialysis Conference,
    and Vasca Inc.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: NKF-K/DOQI clinical practice
guidelines for vascular access: update 2000. Am J Kidney Dis 2001
Jan;37(1 Suppl 1):S137-81.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [National Kidney Foundation (NKF)
Web
site](http://www.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/index.htm).

Print copies: Available from the National Kidney Foundation (NKF), 30
East 33rd St., New York, NY 10016. These guidelines are also available
on CD-ROM from NKF.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Action on access: principles of catheter use for hemodialysis (wall
    chart)

-   Hemodialysis catheters: best practice for early identification and
    management of dysfunction

-   Hemodialysis catheters: preventing and managing dysfunction
    (laminated guide)

-   Hemodialysis vascular access overview: fistula and graft use (wall
    chart)

-   Infection prevention and control: best practices for hemodialysis
    vascular access (laminated guide)

-   Dialysis care package

-   Dialysis care clinical practice guidelines and recommendations
    (CD-ROM)

-   KDOQI in the dialysis center: a quick reference guide

-   CKD: a guide to select NKF-KDOQI guidelines and recommendations 2006

These materials are available by contacting: National Kidney Foundation
30 East 33rd Street, New York, NY 10016 (phone: 212.889.2210 or
800.622.9010 or fax: 212.686.8916), or through the [National Kidney
Foundation Web
site](http://www.kidney.org/professionals/KLS/pdf/KLS_Catalog05_TextLR_1.pdf).

#### PATIENT RESOURCES

The following are available:

-   Hemodialysis catheters: how to keep yours working well (also
    available in Spanish)

-   Vascular access: what you need to know (also available in Spanish)

These patient education materials are available by contacting: National
Kidney Foundation 30 East 33rd Street, New York, NY 10016 (phone:
212.889.2210 or 800.622.9010 or fax: 212.686.8916), or through the
[National Kidney Foundation Web
site](http://www.kidney.org/professionals/KLS/pdf/KLS_Catalog05_TextLR_1.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on September 1, 2001. The information
was verified by the guideline developer as of November 19, 2001. The
updated information was verified by the guideline developer on July 20,
2007.

#### COPYRIGHT STATEMENT

K/DOQI is a trademark of the National Kidney Foundation, Inc. All rights
reserved. No part of this publication may be reproduced or transmitted
in any form or by any means, electronic or mechanical, including
photocopy, recording, or any information storage retrieval system,
without permission in writing from the National Kidney Foundation.

### DISCLAIMER

#### NGC DISCLAIMER

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Guidelines represented on the NGC Web site are submitted by guideline
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<http://www.guideline.gov/about/inclusion.aspx> .

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Readers with questions regarding guideline content are directed to
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Date Modified: 11/3/2008