"Kidneys" Том 8, №3, 2019

Summary of the recommendations

Chapter 1. Medical treatments for promoting arteriovenous fistula maturation

1.1. We suggest any decision to give aspirin, ticlopidine or clopidogrel in adults with end-stage kidney disease (ESKD) during the first 2 months after arteriovenous fistula creation for the sole purpose of improving maturation must balance a reduction in thrombosis against uncertain effects on maturation and bleeding (2C).

1.2. We suggest any decision to give perioperative heparin in adults with end-stage kidney disease during arteriovenous fistula creation must balance an increase in arteriovenous fistula patency at 1 month against an important increase in bleeding complications. (2C).

1.3. We suggest any decision to apply for infrared therapy in adults with end-stage kidney disease during the first 3 months after arteriovenous fistula creation must balance a possible reduction in thrombosis against uncertain effects on maturation and bleeding (2C).

1.4. There are insufficient randomized controlled trial (RCT) data to make a recommendation for ticagrelor, prasugrel, dipyridamole, sulphinpyrazone, warfarin or other oral anticoagulants, fish oil, statins, vonapanitase, glyceryl trinitrate, iontophoretic injection of Salvia miltiorrhiza or prednisolone for improving arteriovenous fistula maturation in adults with end-stage kidney disease (–D).

Advice for clinical practice:

Do not stop mono-antiplatelet treatment in adults undergoing AV access creation.

Chapter 2. Surgical and endovascular interventions for promoting arteriovenous fistula maturation

2.1. We suggest using regional block anaesthesia rather than local anaesthesia for arteriovenous fistula creation in adults with end-stage kidney disease (2C).

2.2. We suggest there is insufficient evidence to support end-of-vein to side-of-artery over side-of-vein to side-of-artery anastomosis for arteriovenous fistula creation in adults with end-stage kidney disease (2C).

Chapter 3. Surgical and endovascular interventions for non-maturing arteriovenous fistulas

3.1. We suggest there is insufficient evidence to support open surgical over endovascular interventions as the preferred treatment for non-maturing arteriovenous fistulas in adults with end-stage kidney disease (2D).

Advice for clinical practice:

Decisions on how to treat non-maturing arteriovenous fistulas are likely best based on local resources, experience and success rates.

Institutions likely benefit from building a dedicated multidisciplinary vascular access team, with clinical experience in various techniques available for non-maturing arteriovenous fistulas.

Chapter 4. Self-administered interventions for arteriovenous fistula maturation

4.1. We suggest that a standardized exercise programme involving hand-and-arm exercises may improve arteriovenous fistula maturation in adults with end-stage kidney disease (2C).

4.2. There is insufficient evidence to support specific exercise programmes or physical interventions to promote AV fistula maturation in adults with end-stage kidney disease (–D).

Advice for clinical practice:

Involving patients more actively in preparing for haemodialysis may improve self-management skills and health literacy and thereby well-being.

Chapter 5. Perioperative prophylactic antibiotics or preventing arteriovenous access infection

5.1. We recommend giving preoperative antibiotic prophylaxis for arteriovenous graft insertion in adults with end-stage kidney disease (1C).

5.2. We suggest giving preoperative antibiotic prophylaxis for complex arteriovenous access procedures in adults with end-stage kidney disease (2D).

5.3. We suggest not giving preoperative antibiotic

prophylaxis for simple arteriovenous access procedures in adults with end-stage kidney disease (2D).

Advice for clinical practice:

Simple arteriovenous access procedures include the creation of a native radiocephalic or native brachiocephalic arteriovenous fistula.

Complex arteriovenous access procedures include those that are not considered simple.

Chapter 6. Timing of first cannulation Arteriovenous fistulas

6.1. In adults requiring haemodialysis, we suggest arteriovenous fistulas can be cannulated 4 weeks after creation if they are considered suitable for cannulation on clinical examination (2C).

6.2. In adults requiring haemodialysis, we recommend against cannulating arteriovenous fistulas sooner than 2 weeks after their creation (1B).

6.3. In adults requiring haemodialysis, we suggest against cannulating arteriovenous fistulas 2–4 weeks after their creation unless this will avoid placement of a central venous catheter for haemodialysis (2C).

Arteriovenous grafts

6.4. In adults requiring haemodialysis, we recommend that ‘early cannulation type’ arteriovenous grafts can be cannulated as soon as wound healing permits (1B).

6.5. In adults requiring haemodialysis, we suggest against cannulating a ‘standard type’ arteriovenous graft sooner than 2 weeks after insertion unless this will avoid placement of a central venous catheter for haemodialysis (2B).

Advice for clinical practice:

In practice, suitability for cannulation on clinical examination is determined by the presence of a palpable vein and good thrill.

If clinical examination is inconclusive, then ultrasound with flow measurement may help in deciding whether to cannulate.

Bedside ultrasound-guided cannulation may be helpful in avoiding complications and decreasing the number of failed cannulations.

Using single-needle dialysis, low dialysis blood

lows and smaller needles (17 gauge) may prevent harm to arteriovenous fistulas that are cannulated early.

Wound healing refers to the tissue around the

body of the graft rather than the incision site.

Chapter 7. Vascular access surveillance

Arteriovenous fistulas

7.1. We suggest the evidence for technical surveillance in addition to clinical monitoring of a functional arteriovenous fistula to detect and pre-emptively correct a haemodynamically important arteriovenous access stenosis in adults is inconclusive and needs more research (2C).

Arteriovenous grafts

7.2. We suggest against technical surveillance in addition to clinical monitoring of a functional arteriovenous graft to detect and pre-emptively correct a haemodynamically important arteriovenous access stenosis in adults unless it occurs in the context of a clinical study (2C).

Chapter 8. Medical treatments for maintaining long-term arteriovenous access patency

Arteriovenous fistulas

8.1. We suggest any decision to give fish oil to adults with end-stage kidney disease in the year following arteriovenous fistula creation must balance improved patency at 1 year against an unknown risk of bleeding and other side effects (2C).

8.2. We suggest far infrared therapy may be considered for improving long-term arteriovenous fistula patency in adults with end-stage kidney disease (2C).

8.3. There are insufficient randomized controlled

trial data to make a recommendation for aspirin, clopidogrel, ticlopidine, warfarin, sulphinpyrazone, vonapanitase, beraprost sodium, cholecalciferol, statins, dipyridamole or dipyridamole combined with aspirin to be given for maintaining long-term arteriovenous fistula patency in adults with end-stage kidney disease (–D).

Arteriovenous grafts

8.4. We recommend against warfarin in combination with antiplatelet agents and against clopidogrel in combination with high-dose aspirin for reducing arteriovenous graft thrombosis in adults with end-stage kidney disease (1C).

8.5. We suggest any decision to give fish oil in the year following arteriovenous graft creation in adults with end-stage kidney disease must balance any improvement in graft patency at 1 year against an unknown risk of bleeding (2C).

8.6. There are insufficient randomized controlled trial data to make a recommendation for aspirin, clopidogrel, ticlopidine, warfarin, beraprost sodium, statins, dipyridamole or dipyridamole combined with aspirin to be given for maintaining long-term arteriovenous graft patency in adults with end-stage kidney disease (–D).

Chapter 9. Cannulation techniques for arteriovenous fistulas

9.1. We suggest against using the area technique for cannulating arteriovenous fistulas in adults treated with haemodialysis (2D).

9.2. We suggest using either a rope-ladder or buttonhole technique for cannulating arteriovenous fistulas in adults treated with haemodialysis and letting the choice be dependent on local expertise and arteriovenous fistula characteristics (2D).

Advice for clinical practice:

Antiseptic measures and practical aspects of the cannulation procedure are important in reducing the infection risk associated with buttonhole cannulation.

Arteriovenous grafts are usually only cannulated using a rope-ladder technique.

Chapter 10. Needle types for arteriovenous fistulas

10.1. We suggest using either sharp needles or plastic cannulas for cannulating arteriovenous fistulas in adults treated with haemodialysis (2C).

10.2. We recommend using blunt needles only

or buttonhole cannulation of arteriovenous fistulas in adults treated with haemodialysis (1D).

Advice for clinical practice:

A quality improvement programme including recording and monitoring of the needle types and cannulation techniques alongside arteriovenous access outcomes can help to monitor quality, guide changes in cannulation practice, if needed, and improve quality of vascular access care.

Arteriovenous grafts are usually only cannulated using sharp steel needles.

Chapter 11. Timing of intervention for arteriovenous fistula thrombosis

11.1. We suggest attempting to declot a thrombosed arteriovenous fistula in adults as soon as possible under optimal conditions and before the next haemodialysis treatment (2D).

11.2. We suggest attempting to declot a thrombosed arteriovenous fistula in adults even if there has been a delay of days to weeks (2D).

Chapter 12. Surgical and endovascular interventions for arteriovenous access thrombosis

12.1. We suggest the choice between surgical and endovascular interventions for arteriovenous access thrombosis be defined by the condition of the patient and their vascular access, as well as local expertise, as there is no evidence one approach improves outcomes over another (2B).