Expert consensus on the establishment and maintenance of native arteriovenous fistula

Vascular access is the lifeline of hemodialysis patients. There are great differences in the establishment and use of vascular access in different countries and regions around the world. We believe that on the basis of good evaluation and planning, it is recommended that hemodialysis patients choose native arteriovenous fistula first. In view of the new progress of vascular access views domestic and international at home and abroad in recent years, we organized experts to recommend the establishment and maintenance of arteriovenous fistula (AVF) for the Chinese population, including preoperative evaluation and planning of the establishment of AVF, AVF surgery, perioperative drug intervention measures and postoperative maintenance, and put forward suggestions for future research directions. The recommendations in this consensus are general and clinicians need to make treatment decisions based on the actual situation.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Structured physical assessment of arteriovenous fistulae in haemodialysis access surveillance: A missed opportunity?

Introduction:

Arteriovenous fistulae remain the gold standard of vascular access in haemodialysis. There is currently no consensus on standardised methods of monitoring arteriovenous fistulae. Assessment techniques and practice remain widely variable. The purpose of this study is to determine whether existing evidence supports physical assessment as an effective tool and a good predictor of arteriovenous fistulae dysfunction to allow for timely intervention and improve outcomes.

Methods:

A literature search was performed using CINAHL, PubMed, Medline and BNI databases and relevant search terms. Studies included were peer-reviewed, published after 2008, in English and related to arteriovenous fistulae only. Six key papers were identified and critically analysed for validity and relevance, in relation to outcomes, assessor experience, training duration and nurses’ ability to perform physical assessment.

Results:

Physical assessment has been shown to be effective in detecting arteriovenous fistulae dysfunction and comparable to technology-based surveillance. Physical assessment techniques generally adopt a ‘look, listen and feel’ approach to identify arteriovenous fistulae dysfunction that includes stenosis, thrombosis, ischaemia and infections. Physical assessment is a skill that can be taught with studies showing that skill-specific training is more effective than experience alone. Cost-effectiveness analysis is lacking.

Conclusion:

The analysis of evidence demonstrates that physical assessment of arteriovenous fistulae is an effective method of detecting arteriovenous fistulae dysfunction and is a skill that can be taught. A structured physical assessment and its implementation may be significant in routine care, but research into the most effective physical assessment techniques and its impact on clinical practice in haemodialysis is required.

Dialysis access procedure training for the nephrologist

Historically, the placement and maintenance of dialysis access has been an integral part of nephrology training. However, in recent years, a big debate has ensued regarding whether this should be limited to trainees' understanding and counseling the patients regarding indications, alternatives, risks and possible complications of these procedures or should it actually involve more of a hands-on experience for the trainees. Some of the barriers in making these procedures a requirement across the board are the lack of standardization of procedural training across various training programs and the absence of consensus on what achieving competency in these procedures looks like. However, in the era of declining interest in nephrology, giving up "ownership" of nephrology procedures and increasing reliance on other sub specialties might be a deterrent in attracting residents to this field; we have to make a concerted effort to increase the exposure and opportunities for the trainees to perform these procedures. Moreover, we need to emphasize the implementation of a curriculum for nephrology fellows to evaluate access properly in order to decrease the burden of access related complications. Lastly, we need to continue working towards a more structured curriculum for a dedicated interventional nephrology fellowship for trainees who want to focus on procedures for their long-term career goals.