The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access
2008; Elsevier BV; Volume: 48; Issue: 5 Linguagem: Inglês
10.1016/j.jvs.2008.08.042
ISSN1097-6809
AutoresAnton N. Sidawy, Lawrence M. Spergel, Anatole Besarab, Michael Allon, William C. Jennings, Frank T. Padberg, M. Hassan Murad, Víctor M. Montori, Ann M. O’Hare, Keith D. Calligaro, Robyn Macsata, Alan B. Lumsden, Enrico Ascher,
Tópico(s)Acute Kidney Injury Research
ResumoRecognizing the impact of the decision making by the dialysis access surgeon on the successful placement of autogenous arteriovenous hemodialysis access, the Society for Vascular Surgery assembled a multispecialty panel to develop practice guidelines in arteriovenous access placement and maintenance with the aim of maximizing the percentage and functionality of autogenous arteriovenous accesses that are placed. The Society commissioned the Knowledge and Encounter Research Unit of the Mayo Clinic College of Medicine, Rochester, Minnesota, to systematically review the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance. The panel then formulated practice guidelines in seven areas: timing of referral to the access surgeon, operative strategies to maximize the placement of autogenous arteriovenous accesses, first choice for the autogenous access, choice of arteriovenous access when a patient is not a suitable candidate for a forearm autogenous access, the role of monitoring and surveillance in arteriovenous access management, conversion of a prosthetic arteriovenous access to a secondary autogenous arteriovenous access, and management of the nonfunctional or failed arteriovenous access. For each of the guidelines, the panel stated the recommendation or suggestion, discussed the evidence or opinion upon which the recommendation or suggestion was made, detailed the values and preferences that influenced the group's decision in formulating the relevant guideline, and discussed technical remarks related to the particular guideline. In addition, detailed information is provided on various configurations of autogenous and prosthetic accesses and technical tips related to their placement. Recognizing the impact of the decision making by the dialysis access surgeon on the successful placement of autogenous arteriovenous hemodialysis access, the Society for Vascular Surgery assembled a multispecialty panel to develop practice guidelines in arteriovenous access placement and maintenance with the aim of maximizing the percentage and functionality of autogenous arteriovenous accesses that are placed. The Society commissioned the Knowledge and Encounter Research Unit of the Mayo Clinic College of Medicine, Rochester, Minnesota, to systematically review the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance. The panel then formulated practice guidelines in seven areas: timing of referral to the access surgeon, operative strategies to maximize the placement of autogenous arteriovenous accesses, first choice for the autogenous access, choice of arteriovenous access when a patient is not a suitable candidate for a forearm autogenous access, the role of monitoring and surveillance in arteriovenous access management, conversion of a prosthetic arteriovenous access to a secondary autogenous arteriovenous access, and management of the nonfunctional or failed arteriovenous access. For each of the guidelines, the panel stated the recommendation or suggestion, discussed the evidence or opinion upon which the recommendation or suggestion was made, detailed the values and preferences that influenced the group's decision in formulating the relevant guideline, and discussed technical remarks related to the particular guideline. In addition, detailed information is provided on various configurations of autogenous and prosthetic accesses and technical tips related to their placement. Autogenous arteriovenous (AV) access for hemodialysis has been shown to be superior to prosthetic graft or catheter access in terms of patient morbidity and mortality. In addition, the maintenance of autogenous AV access is less expensive than prosthetic conduits.1Dhingra R.K. Young E.W. Hulbert-Shearon T.E. Leavey S.F. Port F.K. Type of vascular access and mortality in U.S. hemodialysis patients.Kidney Int. 2001; 60: 1443-1451Crossref PubMed Scopus (330) Google Scholar, 2Young E. Vascular access. American Society of Nephrology, Current practice and practical aspects of management, ASN Renal Week 2000. Toronto2000Google Scholar, 3Murphy G.J. White S.A. Nicholson M.L. Vascular access for haemodialysis.Br J Surg. 2000; 87: 1300-1315Crossref PubMed Scopus (65) Google Scholar, 4Ascher E. Gade P. Hingorani A. Mazzariol F. Gunduz Y. Fodera M. et al.Changes in the practice of angioaccess surgery: impact of dialysis outcome and quality initiative recommendation.J Vasc Surg. 2000; 31: 84-92Abstract Full Text Full Text PDF PubMed Google Scholar, 5Kheriakian G.M. Roedersheimer L.R. Arbaugh J.L. Newmark K.J. King L.R. Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis.Am J Surg. 1986; 152: 238-243Abstract Full Text PDF PubMed Google Scholar Although several reports have shown an autogenous AV access is feasible in most patients in the United States, construction and utilization rates for autogenous AV access for hemodialysis in this country are dramatically lower than in Europe and Japan.6Jennings W.C. Creating arteriovenous fistulas in 132 consecutive patients: exploiting the proximal radial artery arteriovenous fistula: reliable, safe and simple forearm and upper arm hemodialysis access.Arch Surg. 2006; 141 (discussion 32): 27-32Crossref PubMed Scopus (50) Google Scholar, 7Nguyn V.D. Griffith C. Treat L. A multidisciplinary approach to increasing AV fistula creation.Nephrol News Issues. 2003; 17: 54-56Google Scholar Nevertheless, rates of autogenous AV access within the United States have improved in the last several years. This important progress likely reflects the effect of national efforts to increase autogenous access placement, such as the Centers for Medicare and Medicaid Services (CMS)–sponsored AV Fistula First Breakthrough Initiative (FFBI) and the National Kidney Foundation (NKF)-Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines,8Lok C.E. “Fistula first initiative: advantages and pitfalls.”.Clin J Am Soc Nephrol. 2007; 2: 1043-1053Crossref PubMed Scopus (51) Google Scholar, 9National Kidney Foundation's KDOQI 2006 Vascular Access Guidelines.Am J Kidney Disease. 2006; 48: S177-S322Google Scholar as well as improved preoperative evaluation, vessel mapping, and accepted priority for autogenous access. The development of alternative and innovative approaches to autogenous AV access construction has also contributed to wider utilization of autogenous access in this country.10Arteriovenous Fistula First Breakthrough Coalitionhttp://www.fistulafirst.orgGoogle Scholar Ten years ago, in October 1997, the NKF-KDOQI Clinical Practice Guidelines for Vascular Access were published in an effort to increase the placement of autogenous AV access and to prolong the use of existing access by detection of, and timely intervention for, dysfunction. These original guidelines and subsequent versions stress proactive identification of patients with progressive kidney disease, identification and protection of potential native access construction sites by members of the health care team and patients, and the development of a multifaceted quality assurance program to detect at-risk vascular access, track complication rates, and implement procedures that maximize access longevity. The original guidelines recommended that autogenous AV access be constructed in at least 50% of all new renal failure patients electing to receive hemodialysis as their initial form of renal replacement therapy, with the expectation that ultimately, 40% of prevalent patients would be receiving their hemodialysis through an autogenous AV access.11National Kidney Foundation. KDOQI guidelineshttp://www.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/index.htmGoogle Scholar The 2006 updated KDOQI Guidelines raised this benchmark for minimal use of autogenous access in prevalent hemodialysis patients to 65%.9National Kidney Foundation's KDOQI 2006 Vascular Access Guidelines.Am J Kidney Disease. 2006; 48: S177-S322Google Scholar In June 2003, a coalition consisting of the CMS, the End-Stage Renal Disease (ESRD) Networks, the Institute for Healthcare Improvement (IHI), and other key provider representatives jointly recommended adoption of a National Vascular Access Improvement Initiative (NVAII). The initial goal of this initiative was to increase the number of autogenous AV accesses placed and functioning in suitable patients to meet or even surpass the targets set by NKF-KDOQI guidelines. The NVAII was originally intended to run through 2003; but because of early success in reaching the then-KDOQI goal of 40% prevalence by August 2005, CMS formally expanded its commitment by upgrading the initiative to what CMS called the AV Fistula First Breakthrough Initiative (FFBI), with a new goal of 66% by 2009.10Arteriovenous Fistula First Breakthrough Coalitionhttp://www.fistulafirst.orgGoogle Scholar The FFBI Work Group identified clinical and organizational changes that could be adapted and applied locally by nephrologists, dialysis personnel, access surgeons, and patients to increase the production and use of autogenous AV access. They also identified system changes that could be implemented at a national level to encourage the placement of autogenous AV accesses at a higher rate than prosthetic AV accesses and catheters, for example, reimbursement for preoperative vessel mapping to identify adequate vessels for use for autogenous access construction. As a result of the efforts of the FFBI, the prevalence of autogenous access had increased by >50%, from 32% to 49%, by January 2008. The Society for Vascular Surgery (SVS), representing >2500 vascular surgeons, recognizes the effect of decision making by the individual vascular access surgeon on the construction and utilization of access for hemodialysis. Therefore, the SVS approved and sponsored two initiatives: (1) to develop and publish reporting standards for AV hemodialysis access and (2) to develop practice guidelines for AV hemodialysis access. To accomplish the first initiative, the SVS charged a multidisciplinary committee to develop standardized definitions related to AV access procedures, patency, and complications. Standardization of terminology facilitates more meaningful comparisons between published reports of long-term patency and complications of AV access procedures. These recommendations were published in the Journal of Vascular Surgery in 2002.12Sidawy A.N. Gray R. Besarab A. Henry M. Ascher E. Silva Jr, M. et al.Recommended standards for reports dealing with arteriovenous hemodialysis accesses.J Vasc Surg. 2002; 35: 603-610Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar To accomplish the second initiative, SVS assembled a multispecialty expert panel, consisting of vascular access surgeons and nephrologists, to develop clinical practice guidelines for AV access placement. In an ongoing effort to optimize the placement of autogenous AV access in patients with chronic kidney disease (CKD) and ESRD, these guidelines are directed toward AV access surgeons and specialists (such as interventional radiologists, nephrologists, and cardiologists) as the providers whose ultimate operative decision determines the type of access placed. The panel's recommendations have culminated in the following practice guidelines: optimal timing and indications for referral of patients with advanced CKD, defined by a Modification of Diet in Renal Disease (MDRD) glomerular filtration rate (GFR) of >20 to 25 mL/min, to a vascular access surgeon, preoperative evaluation for AV access, configuration and strategies to optimize autogenous AV access placement, assessment of functionality of AV access, and treatment of AV access thrombosis. To help the panel formulate its recommendations, the SVS used the help of The Knowledge and Encounter Research Unit (KER) of the Mayo Clinic College of Medicine, Rochester, Minnesota. This independent group performed a systematic study of the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance.13Murad M.H. Sidawy A.N. Elamin M.B. Rizvi A.Z. Flynn D.N. McCausland F.R. et al.Timing of referral for chronic hemodialysis vascular access placement: a systematic review.J Vasc Surg. 2008; 48: 31S-33SAbstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 14Murad M.H. Elamin M.B. Sidawy A.N. Malaga G. Rizvi A. Flynn D. et al.Autogenous vs prosthetic vascular access for hemodialysis: a systematic review and meta-analysis.J Vasc Surg. 2008; 48: 34S-47SAbstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 15Casey E. Murad M.H. Rizvi A. Sidawy A.N. McGrath M.M. Elamin M.B. et al.Surveillance of arteriovenous hemodialysis access: a systematic review and meta-analysis.J Vasc Surg. 2008; 48: 48S-54SAbstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The panel adopted the Grading of Recommendations Assessment, Development and Evaluation (GRADE) scheme to formulate these recommendations because this system separates the strength of recommendations from the quality of the evidence.16Atkins D. Best D. Briss P.A. Eccles M. Falck-Ytter Y. Flottorp S. et al.Grading quality of evidence and strength of recommendations.BMJ. 2004; 328: 1490Crossref PubMed Google Scholar This separation informs guideline users (eg, patients, clinicians, and policy makers) of factors other than evidence, such as values and preferences if applicable, and clinical and social circumstances that played a role in formulating these recommendations. These systematic literature reviews revealed a paucity of high-quality evidence in this area, and many of the recommendations herein are based on observational studies, unsystematic observations, and consensus of our committee. Nevertheless, some of these recommendations were graded as strong (GRADE 1) because of the values and preferences brought to bear by the committee and are explicitly described in this article. In addition, because of the multidisciplinary nature of the committee, these recommendations reflect consensus among access surgeons and nephrologists. Although by spearheading this project the SVS aimed to provide a structure to form the underpinning of patient evaluation and decision making by the access surgeon, it is important to emphasize that these recommendations are not intended to supersede the surgeon's final judgment regarding the management of the individual patient. We recommend that patients with advanced CKD disease (late stage 4, MDRD <20 to 25 mL/min) who have elected hemodialysis as their choice of renal replacement therapy be referred to an access surgeon in order to evaluate and plan construction of AV access (GRADE 1 recommendation, very low-quality evidence). AIf at the conclusion of the evaluation, upper extremity arterial and venous anatomy is adequate for an autogenous AV access, such access should be constructed as soon as possible to allow it enough time to mature and undergo further interventions that may be needed to ensure that the access is ready to be used when dialysis is initiated.BIf a prosthetic access is to be constructed, this should be delayed until just before the need for dialysis. A systematic review of the literature demonstrated that the evidence on the appropriate timing of referring patients to vascular surgery is very scarce.13Murad M.H. Sidawy A.N. Elamin M.B. Rizvi A.Z. Flynn D.N. McCausland F.R. et al.Timing of referral for chronic hemodialysis vascular access placement: a systematic review.J Vasc Surg. 2008; 48: 31S-33SAbstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Two observational studies demonstrated that 1 month before hemodialysis was initiated used a catheter as their first access17Besarab A. Adams M. Amatucci S. Bowe D. Deane J. Ketchen K. et al.Unraveling the realities of vascular access: the Network 11 experience.Adv Ren Replace Ther. 2000; 7: S65-S70PubMed Google Scholar and that, compared with late access construction (≤1 month of hemodialysis), early access construction (≥4 months before hemodialysis) was associated with lower risk of death and sepsis, with relative risks (RRs) of 0.76 (95% confidence interval [CI], 0.58-1.00) and 0.57 (95% CI, 0.41-0.79), respectively.18Oliver M.J. Rothwell D.M. Fung K. Hux J.E. Lok C.E. Late creation of vascular access for hemodialysis and increased risk of sepsis.J Am Soc Nephrol. 2004; 15: 1936-1942Crossref PubMed Scopus (53) Google Scholar Introducing catheter use and sepsis into the mortality model rendered the association nonsignificant. It is difficult to predict the timing of hemodialysis onset in an individual patient19Lacson Jr, E. Lazarus J.M. Himmelfarb J. Ikizler T.A. Hakim R.M. Balancing Fistula First with Catheters Last.Am J Kidney Dis. 2007; 50: 379-395Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar; however, observations of the committee members suggest that access placement <6 months before initiation of hemodialysis is unlikely to allow adequate time for autogenous access maturation. Timely discussion and consultation could help avoid these adverse outcomes. In addition, according to unsystematic observations and consensus of our committee, prosthetic AV accesses should be placed no earlier than 3 to 6 weeks before an anticipated need for hemodialysis in patients who are not candidates for autogenous AV accesses. This is because the lifespan of prosthetic accesses is limited by venous outflow stenosis, which can develop at any time after access placement, regardless of when hemodialysis is initiated through the access. In addition, the prosthetic access only needs 3 to 6 weeks for incorporation in the surrounding tissue, and at many centers, a prosthetic access is used ≤2 weeks of placement or earlier, depending on the type of prosthetic access. This recommendation is consistent with those of KDOQI and the FFBI.8Lok C.E. “Fistula first initiative: advantages and pitfalls.”.Clin J Am Soc Nephrol. 2007; 2: 1043-1053Crossref PubMed Scopus (51) Google Scholar, 9National Kidney Foundation's KDOQI 2006 Vascular Access Guidelines.Am J Kidney Disease. 2006; 48: S177-S322Google Scholar In formulating a strong recommendation despite the very low-quality evidence, the committee placed a higher value on avoiding harm associated with late access construction and a lower value on potential harms and costs associated with early referral and early access placement. Early referral should encourage placement of autogenous access; however, whether the autogenous access prevalence rate can be increased to reach 66% by 2009, as desired by CMS,8Lok C.E. “Fistula first initiative: advantages and pitfalls.”.Clin J Am Soc Nephrol. 2007; 2: 1043-1053Crossref PubMed Scopus (51) Google Scholar is currently uncertain. It is generally agreed that all new hemodialysis patients should have the most optimal permanent vascular access that can be successfully used at the time of initiation of dialysis therapy. For this to happen, the patient must see a nephrologist before initiation of dialysis to facilitate the referral to an access surgeon, and the surgery must be performed in enough time before dialysis initiation to allow for maturation, revision, and repeat procedures if the first attempt is unsuccessful. Referral for initial vascular access placement should ideally occur approximately 6 months in advance of the anticipated need for dialysis. Because of the difficulty of predicting timing of onset of hemodialysis in an individual patient, it is recommended that referral for initial access placement should occur when the estimated GFR (eGFR) level drops <20 to 25 mL/min/1.73 m2 (stage 4 CKD) in a patient expected to start hemodialysis. However, referral decisions should be individualized to reflect differences in rates of actual and predicted decline in eGFR, in the competing risk of death, and in patient preferences. In the United States, most patients who start dialysis do not have a functioning permanent vascular access (autogenous or prosthetic) in place at the time dialysis is initiated, and thus a catheter must be used for dialysis until permanent access is placed and ready to be used.20Lee T. Barker J. Allon M. Associations with predialysis vascular access management.Am J Kidney Dis. 2004; 43: 1008-1013Abstract Full Text Full Text PDF PubMed Google Scholar, 21Pisoni R.L. Young E.W. Dykstra DM, Greenwood R.N. Hecking E. Gillespie B. et al.Vascular access use in Europe and the United States: results from the DOPPS.Kidney Int. 2002; 61: 305-316Crossref PubMed Scopus (459) Google Scholar Many patients are not referred to a nephrologist until their kidney disease is already quite advanced, allowing little opportunity for vascular access placement before dialysis is initiated.17Besarab A. Adams M. Amatucci S. Bowe D. Deane J. Ketchen K. et al.Unraveling the realities of vascular access: the Network 11 experience.Adv Ren Replace Ther. 2000; 7: S65-S70PubMed Google Scholar, 22Arora P. Obrador G.T. Ruthazer R. Kausz A.T. Meyer K.B. Jenuleson C.S. et al.Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center.J Am Soc Nephrol. 1999; 10: 1281-1286PubMed Google Scholar, 23Patel U.D. Young E.W. Ojo A.O. Hayward R.A. CKD progression and mortality among older patients with diabetes.Am J Kidney Dis. 2005; 46: 406-414Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Not surprisingly, patients who are referred to nephrologists before the initiation of dialysis are more likely to undergo vascular access surgery before dialysis begins.24Avorn J. Winkelmayer W.C. Bohn R.L. Levin R. Glynn R.J. Levy E. et al.Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure.J Clin Epidemiol. 2002; 55: 711-716Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar More frequent utilization of nephrology care before the initiation of dialysis also appears to be associated with a lower risk of catheter use at the initiation of dialysis.24Avorn J. Winkelmayer W.C. Bohn R.L. Levin R. Glynn R.J. Levy E. et al.Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure.J Clin Epidemiol. 2002; 55: 711-716Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Avorn et al24Avorn J. Winkelmayer W.C. Bohn R.L. Levin R. Glynn R.J. Levy E. et al.Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure.J Clin Epidemiol. 2002; 55: 711-716Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar found that patients referred to a nephrologist 90 days before the initiation of dialysis. Frequency of nephrology care was also important. Those who had fewer than three visits to a nephrologist within the year before dialysis initiation were 40% more likely to have a catheter than those who had three or more visits.24Avorn J. Winkelmayer W.C. Bohn R.L. Levin R. Glynn R.J. Levy E. et al.Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure.J Clin Epidemiol. 2002; 55: 711-716Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar In addition, predialysis nephrology referral is associated with a shorter duration of catheter use after the initiation of dialysis and with a greater likelihood of autogenous access placement.25Astor B.C. Eustace J.A. Powe N.R. Klag M.J. Sadler J.H. Fink N.E. et al.Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.Am J Kidney Dis. 2001; 38: 494-501Abstract Full Text Full Text PDF PubMed Google Scholar Nevertheless, even among patients referred to a nephrologist well in advance of the need for dialysis, most start dialysis with a catheter rather than a permanent vascular access.20Lee T. Barker J. Allon M. Associations with predialysis vascular access management.Am J Kidney Dis. 2004; 43: 1008-1013Abstract Full Text Full Text PDF PubMed Google Scholar, 22Arora P. Obrador G.T. Ruthazer R. Kausz A.T. Meyer K.B. Jenuleson C.S. et al.Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center.J Am Soc Nephrol. 1999; 10: 1281-1286PubMed Google Scholar, 25Astor B.C. Eustace J.A. Powe N.R. Klag M.J. Sadler J.H. Fink N.E. et al.Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.Am J Kidney Dis. 2001; 38: 494-501Abstract Full Text Full Text PDF PubMed Google Scholar Therefore, the need for CKD/pre-ESRD programs is crucial to ensuring that patients are evaluated early to receive the optimal renal replacement therapy and permanent hemodialysis access (if hemodialysis is chosen). The average maturation time of a new autogenous access is 2 to 4 months.26Allon M. Lockhart M.E. Lilly R.Z. Gallichio M.H. Young C.J. Barker J. et al.Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients.Kidney Int. 2001; 60: 2013-2020Crossref PubMed Scopus (177) Google Scholar, 27Allon M. Robbin M.L. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions.Kidney Int. 2002; 62: 1109-1124Crossref PubMed Google Scholar, 28Dixon B.S. Novak L. Fangman J. Hemodialysis vascular access survival: upper-arm native arteriovenous fistula.Am J Kidney Dis. 2002; 39: 92-101Abstract Full Text Full Text PDF PubMed Google Scholar, 29Miller P.E. Tolwani A. Luscy C.P. Deierhoi M.H. Bailey R. Redden D.T. et al.Predictors of adequacy of arteriovenous fistulas in hemodialysis patients.Kidney Int. 1999; 56: 275-280Crossref PubMed Scopus (199) Google Scholar, 30Oliver M.J. McCann R.L. Indridason O.S. Butterly D.W. Schwab S.J. Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas.Kidney Int. 2001; 60: 1532-1539Crossref PubMed Scopus (111) Google Scholar In addition, a patient whose access fails to mature sufficiently to support hemodialysis needs to undergo additional procedures to promote autogenous access maturation or place a new vascular access, or both. Hemodialysis patients are usually dialyzed through a central venous catheter while this process is completed. Catheter use is associated with bacteremia and inadequate dialysis, which is time/use-related.31Schwab S.J. Beathard G. The hemodialysis catheter conundrum: hate living with them, but can't live without them.Kidney Int. 1999; 56: 1-17Crossref PubMed Scopus (232) Google Scholar Catheter use at initiation of dialysis is also associated with higher subsequent mortality.32Ortega T. Ortega F. Diaz-Corte C. Rebollo P. Ma Baltar J. Alvarez-Grande J. The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management.Nephrol Dial Transplant. 2005; 20: 598-603Crossref PubMed Scopus (52) Google Scholar, 33Pastan S. Soucie J.M. McClellan W.M. Vascular access and increased risk of death among hemodialysis patients.Kidney Int. 2002; 62: 620-626Crossref PubMed Scopus (233) Google Scholar, 34Astor B.C. Eustace J.A. Powe N.R. Klag M.J. Fink N.E. Coresh J. Type of vascular access and survival among incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study.J Am Soc Nephrol. 2005; 16: 1449-1455Crossref PubMed Scopus (138) Google Scholar Furthermore, mortality is higher among patients who receive dialyses continuously through a catheter than among those who switch from a catheter to autogenous or prosthetic permanent access.35Allon M. Daugirdas J. Depner T.A. Greene T. Ornt D. Schwab S.J. Effect of change in vascular access on patient mortality in hemodialysis patients.Am J Kidney Dis. 2006; 47: 469-477Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar It should be noted that it is unclear from these studies whether catheter use directly causes higher mortality or whether catheter use is a marker for other conditions and situations associated with increased mortality risk. In addition to central vein preservation, peripheral upper extremity veins should also be preserved for future placement of permanent vascular access; therefore whenever possible, hand veins should be used in preference to arm veins for phlebotomy and intravenous catheter placement in patients with CKD, despite the increased discomfort for patients. Particular care should be taken to avoid cannulation of the cephalic vein in the nondominant arm. When arm veins must be used, the site should be rotated. Percutaneous intravenous central catheters (PICCs) should not be used in patients with evidence of renal dysfunction until their renal status is evaluated. Because of low rates of autogenous access placement among incident hemodialysis patients, time required for successful autogenous access maturation, and associations of catheter use with adverse outcomes among hemodialysis patients, there is ready consensus that patients with CKD should be referred for autogenous access placement well before the initiation of dialysis. However, scant information is available to suggest exactly how far in advance of the need for dialysis and when in relation to their level of renal function and course of their CKD patients should be referred for initial AV access construction. Consequently, although there is broad agreement among different national guidelines that timely referral for autogenous access construction is important, specific recommendations are opinion-based and vary considerably, as indicated by various pub
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