It shouldn’t be Fistula First, or Catheter Last. The best approach, if evidence shows it, should be individualized for placing a patient’s vascular access.

That’s the direction Charmaine Lok, MD, will be taking over the next 18 months as she directs workgroups to revise the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative guidelines which, along with nutrition guidelines, are under review this year. “The prior messages were ‘Fistula First, Catheter Last, Functioning Fistula First’ – we are not going to necessarily do that. What we want is individualized care with standardized processes,” Lok said during a session on the guidelines at the National Kidney Foundation’s Spring Clinical Meetings held last week in Boston. The vascular access guidelines were last updated in 2006.

The NKF has completed revisions to its hemodialysis adequacy guidelines. The nutrition guidelines, being revised in partnership with the Academy of Nutrition and Dietetics and directed by Alison Steiber, PhD, RD, LD, will see their first update since 2000. Steiber, the academy’s chief scientific officer, said the revisions should be ready by early 2018. The guidelines will cover patients in CKD stages 1-5, on dialysis, and those with a transplant.

She told NKF attendees that the workgroup will also take a more evidence-based approach compared to the original guidelines; close to 70% of those were opinion-based, she said. The academy, through its Renal Dietetic Practice Group, released its own set of nutritional guidelines, focused on pre-dialysis patients, in 2010.

While the revised guidelines will be strengthened by the availability of more nutritional research, Steiber said renal dietetics still suffer from a lack of good studies. “[Nutrition] doesn’t have the traditional RCTs that other areas of medicine do,” she said, acknowledging, “We won’t be purely RCT-driven” in updating the guidelines. Three workgroups will be assigned to cover patient assessment, diagnosis, monitoring, prevention, and treatment. The researchers started with more than 9,000 hits on nutrition-focused search terms, and have reviewed 2,800 citations to date.

A multidisciplinary review for dialysis vascular access

One of the keys to developing an individualized approach for dialysis access placement, said Lok, is taking a multidisciplinary review. “We are including nephrology, surgery, and interventional nephrology and radiology, plus epidemiology and statistics” in developing the guidelines, she said during her presentation. The focus will be on developing a “life plan” for a patient’s dialysis access needs. That could involve starting with a peritoneal dialysis catheter, moving to a hemodialysis fistula, placing a graft for perhaps a home dialysis application if the fistula fails, and perhaps seeing a transplant in between those options.

“We also don’t want to just look at access type: we want to look at the placement timeline for pre-access, the access during dialysis, and post-access” to monitor its health and patency once it is placed. The workgroup will also look closely at new access technology, “keeping an open mind for the future” on access options.

The Scope of Work approach for the KDOQI access guidelines will include:

  • Timing, selection, and placement of access
  • Cannulation
  • Detection of access dysfunction
  • Treatment of AV access complications

Techniques for vein preservation will also be covered.

To date, the workgroup has reviewed 4,126 abstracts, and 1,350 manuscripts are being read, said Lok.

More information on the KDOQI guideline development process is available at