UK Kidney Association Clinical Practice Guideline on vascular access for haemodialysis

Abstract: This guideline is written primarily for doctors and nurses working in dialysis centres and related areas of medicine in the UK, and is an update of a previous version written in 2015. It aims to provide guidance on how to provide vascular access care for patients approaching and undergoing haemodialysis, and provides a standard of care which centres should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: “What does good quality vascular access care look like?”. The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to – most of this is freely available online, at least in summary form.

A few notes on the individual sections: This section covers key concepts relevant to vascular access and focusses on access type selection, including a historical introduction and review of the key literature informing our understanding. This explains why we are moving away from the outdated advice in previous guidelines (e.g. that ‘all patients should dialyse with a fistula as first choice’) towards a process which treats dialysis access selection as a choice, respecting patient individuality, aiming to provide high quality assessment and advice, so that patients are supported in making informed decisions. The basic concept of the fistula as optimal access is highlighted and remains valid, but it is placed within a more modern concept of care, in which the patient is at the centre of the decision process. This section addresses the initial planning of access, from education and vein preservation, through to the timing of assessment and access formation, emphasising in particular the need to plan ahead. This section deals with the formation and routine care of AV access (fistulas and grafts), covering access type and configuration, surgical and anaesthetic technique, the maturation period (before a fistula is ready to be used), and initiation and maintenance of optimal cannulation (needling). This section deals with some of the complications of AV access. Research in this area is ongoing and not yet sufficient to give clear guidance, so we emphasise again the importance of involving patients in treatment decisions. This section deals with the placement and routine care of catheter access (lines), covering location, technique, anticoagulant locks, and regular exit site disinfection and dressings. This section deals with catheter complications, like infection and poor flow, which are sometimes life-threatening, and for which the catheter sometimes needs to be changed. This section deals with central venous stenosis (narrowing of veins deep in the chest) which is mostly a long term complication of catheters, but which is relevant to the planning of all types of access. We thought this important condition deserved its own section.

This section covers key concepts relevant to vascular access and focusses on access type selection, including a historical introduction and review of the key literature informing our understanding. This explains why we are moving away from the outdated advice in previous guidelines (e.g. that ‘all patients should dialyse with a fistula as first choice’) towards a process which treats dialysis access selection as a choice, respecting patient individuality, aiming to provide high quality assessment and advice, so that patients are supported in making informed decisions. The basic concept of the fistula as optimal access is highlighted and remains valid, but it is placed within a more modern concept of care, in which the patient is at the centre of the decision process.

This section addresses the initial planning of access, from education and vein preservation, through to the timing of assessment and access formation, emphasising in particular the need to plan ahead.

This section deals with the formation and routine care of AV access (fistulas and grafts), covering access type and configuration, surgical and anaesthetic technique, the maturation period (before a fistula is ready to be used), and initiation and maintenance of optimal cannulation (needling).

This section deals with some of the complications of AV access. Research in this area is ongoing and not yet sufficient to give clear guidance, so we emphasise again the importance of involving patients in treatment decisions.

This section deals with the placement and routine care of catheter access (lines), covering location, technique, anticoagulant locks, and regular exit site disinfection and dressings.

This section deals with catheter complications, like infection and poor flow, which are sometimes life-threatening, and for which the catheter sometimes needs to be changed.

This section deals with central venous stenosis (narrowing of veins deep in the chest) which is mostly a long term complication of catheters, but which is relevant to the planning of all types of access. We thought this important condition deserved its own section.

Most of the concepts relevant to adult patients apply equally to children and adolescents, so there is no separate Paediatric section, and unless stated, guidance applies to children as well as adults. Where they do exist, differences are highlighted within the statements and rationale, sometimes with separate paragraphs or subheadings. Access for peritoneal dialysis is not included in this guideline since it is covered elsewhere, and the guideline is not exhaustive, with several aspects not covered, though they may be addressed in future versions. The guideline’s principle focus is areas of mainstream practice for which there is variation across different UK centres, in general not covering newly developed or rarely practiced techniques, and it is not intended to replace handbooks and review articles. The guideline’s main anticipated audience is NHS professionals caring for patients who are receiving or planning haemodialysis, but it is written to be as accessible as possible to patients and carers also. There are appendices at the end which explain the meaning of words and concepts which are used throughout the guideline, especially the medical and statistical terminology.

Clinical trial number: Not applicable.