Vascular Access for Haemodialysis

Final Draft Version (26 October 2010) Posted on www.renal.org

Authors of this guideline were:

Dr Richard Fluck at Derby Hospitals NHS Foundation Trust and Dr Mick Kumwenda at Betsi Cadwaladr University Health

Introduction

Vascular access remains a key component of haemodialysis. The ideal vascular access should provide safe and effective therapy by enabling the removal and return of blood via an extracorporeal circuit. Vascular access should be easy to use, reliable and have minimal risk to the individual receiving haemodialysis. However, the provision of good quality access, whilst it is a fundamental aspect of the treatment of haemodialysis patients, remains difficult to achieve.

Native access, in particular arteriovenous fistulae, requires prior planning yet has a high primary failure rate. Arteriovenous grafts utilizing replacement of synthetic or biological material in conjunction with native vessels again require planning and surgical expertise yet have a high demand to maintain them and a high rate of complications. Venous catheters (both tunnelled and non-tunnelled) are in common usage both as temporary access and in a smaller number of patients as the only form of access that is available, yet offer inferior therapy. Vascular access via central venous catheters provides poorer solute clearance related to the limited achieved blood flow and also a higher rate of complications.

This guideline updates the section on vascular access in the haemodialysis module of the 4th edition of the RA guidelines published on-line at www.renal.org in 2007. These guideline recommendations are based on a literature review from relevant publications in journals cited on MEDLINE, PubMed and UpToDate up to 1^st May 2010. The modified GRADE system has been adopted by the Renal Association Clinical Practice Guidelines Committee and has been used to grade the recommendations in all of the modules in the 5^th edition of the Renal Association guidelines. It explicitly describes both the strength of the recommendations and the quality of the underlying evidence, with the aim of maximising applicability to standard clinical practice (1-4). The modified GRADE system grades level of expert recommendation as “strong” (Grade 1) or “weak” (Grade 2) according to balance of benefits, risk, burden and cost. The quality or level of evidence is assessed as “high” (Grade A), “moderate” (Grade B), “low” (Grade C) or “very low” (D) depending on factors such as study design, directness of evidence and consistency of results (1-4).

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