The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) provides evidence-based clinical practice guidelines for haemodialysis vascular access and related complications, and has done so since 1997. The latest guidelines, published in 2006, no longer reflect the most recent evidence for the management of vascular access, causing the haemodialysis and vascular access community to eagerly await the revised recommendations, currently in the external review process and due in Spring 2019.
With more than a decade between the last guidelines and the imminently anticipated ones, the time elapsed is reflected in numbers: the new guidelines will have over 160 statements, compared with the 130 statements of the 2006 guidelines. For the upcoming guidelines, approximately one-third of these statements are based on a rigorous review process, and two thirds predicated on expert opinion. In contrast, the previous guidelines—where the strength of the recommendation was given a letter grade, with A being backed by the strongest evidence—had <20% grade A statements, and the remainder grade B or expert opinion.
Charmaine Lok (University of Toronto, Toronto, Canada), chair of the KDOQI guidelines for vascular access 2018, gave a talk at the Controversies and Updates in Vascular Surgery conference (CACVS; 7–9 February, Paris, France) to provide a glimpse of the upcoming guidelines. When asked by an audience member if the 13 years between guidelines meant there was “a big risk of having an outdated practice in-between” the publications, Lok agreed, telling delegates: “Absolutely. That is why it took us so long to develop the guidelines, because there was such a significant amount of evidence that had to be reviewed. The benefit of having a long time between each is that it allowed time for studies to be conducted, so we could actually learn from them to help develop the next guidelines, but I agree with you.
“There has actually been a study on the ideal time-frame between guidelines: four years. We need to keep these guidelines ongoing. This was a complete renewal of the guidelines, so hopefully the next ones will truly be an update, to make them much more frequent, because the time lapses are far too great.”
Lok told CACVS attendees that there had been several key conceptual shifts involved with this endeavour, to ensure the finished publication best mirrors the changes to the field in the intervening 13 years.
Expanding on one of these ideological changes at CACVS, Lok said: “Here is one of the biggest changes in concept: what we are trying to do is emphasise the end-stage kidney disease (ESKD) life-plan. Everybody is well aware that chronic kidney disease has five stages, and we typically think about reaching stage V, which is ESKD, as the end. However, I really want you to rethink it. When a patient reaches stage V, that is the beginning of the patient’s ESKD life on dialysis or transplant. The beginning of their ESKD life-plan.”
Lok went on to explain that the endstage kidney disease life-plan concept centred around the paradigm of attaining: “The right access, in the right patient, at the right time, for the right reasons”. This, Lok said, means thinking of and planning for the patient’s continued care across their entire ESKD lifetime. She demonstrates this with an example of two patients, a teenager whose ideal treatment would be a preemptive transplant, and an obese comorbid adult man, who “may have a different trajectory.”
In addition to reconfiguring the approach to end-stage kidney disease treatment to encompass the complete patient timeline, the new guidelines consider and encompass more than the focused “fistula first” concept that Lok describes as emphasised since the 2006 recommendations. Instead, Lok asked the attending physicians to focus on a four-step PLAN (Patient Life-plan, Access Needs).
The first step of the PLAN involves considering the patient first, and what their ESKD life-plan looks like. Is the first ESKD modality choice haemodialysis or peritoneal dialysis? Or transplant? Given that it is haemodialysis, next, consider their access needs. Secondly, what is the access creation plan; for example, who will create the access, where (location) and when (timing). Thirdly, the physicians are asked to come up with an access contingency plan, so they have a remedial plan for when the access becomes problematic; for example, before creating the fistula, or to consider the plan of action if it fails to mature. Finally, Lok urged the CACVS audience to think about an access succession plan, before creating an access: it’s not just thinking about fistula first, but what access is next. This takes into account the patient’s life-plan and the longer-term plan. Lok said that it was “especially important to think cleverly about this for younger patients, who have a whole life ahead of them.”
Changes to definitions
A further change outlined by Lok in her CACVS presentation, more pedantic than the overarching conceptual changes described above, is the editing of several definitions. One such changed definition is “catheter dysfunction”. Previously, this had focused on blood pump speed, and was defined in 2006 to include the “failure to attain and maintain an extracorporeal blood flow of 300ml/min or greater at a prepump arterial pressure more negative than 250mmHg.” The new guidelines will define catheter dysfunction thus: “Failure to maintain the prescribed extracorporeal blood flow required for adequate haemodialysis without lengthening the prescribed HD treatment.”
Lok explained: “In some situations as in Tassin, France or for patients receiving nocturnal haemodialysis, these patients undergo longer duration dialysis, at prescribed low blood pump speeds (<300 ml/min) and the patient’s catheter is fine—you would not say it is malfunctioning. So with these guidelines, we looked at innovation in [the] dialysis [field], and how we might be able to keep definitions current.”