The term “lifeline” has frequently been used to describe a hemodialysis vascular access. Whether this lifeline is an arteriovenous fistula (AVF), arteriovenous graft (AVG), or tunneled dialysis catheter (TDC), a host of complications are possible. In fact, vascular access complications account for approximately 20-30% of hospital admission for hemodialysis (HD) patients. While numerous trials have been conducted with the goal of optimizing vascular access outcomes, little success has been achieved due to issues of interpretability and applicability, a lack of relevant outcomes as well as inconsistent outcome reporting.

In a Special Report published in AJKD, Viecelli et al report on the development of a core outcome measure for vascular access to be used across all HD trials. The workshop contributors included patients, caregivers, and health professionals. From their discussions, five themes were identified:

• capturing the broad applicability of function
• emphasizing experiential relevance and severity
• demonstrating feasibility of implementation
• ensuring robustness and validity
• integrating patients’ values and preferences

The workshop participants deemed function to be the most important vascular access outcome. They further emphasized that it is solely function, and not infectious complications nor cannulation issues, that possessed the most relevance across all access types (AVFs, AVGs, and TDCs). The effectiveness of an access was thought to be highly dependent on a multidisciplinary approach to care which included the patient, nurses, technicians, surgeons, and nephrologists. A well-functioning access was also associated with an improved quality of life and impacted various aspects of health, well-being, and quality of care.

Numerous factors contribute to a well-functioning access, including but not limited to the ease of cannulation, the ability to achieve prescribed blood flow rates, and achieving adequate dialysis (adequate Kt/V). The group defined function as the ability to achieve uninterrupted and adequate dialysis without the need for interventions. Viecelli et al concluded that reporting vascular access function consistently across trials would allow for improved comparison of the effectiveness of interventions across trials, provide information on the performance of vascular access function in different clinical settings, and deliver a useful quality improvement tool.

Table 1 from Viecelli et al, AJKD © National Kidney Foundation.

As an interventional nephrologist, such a measure is crucial to my practice. Moving forward,  the hope is that such a measure will help guide our decision-making regarding which clinical scenarios warrant intervention so as to improve patient outcomes.

– Post prepared by Sean Kalloo, AJKD Blog Contributor

To view Viecelli et al (subscription required), please visit AJKD.org.

Title: Report of the Standardized Outcomes in Nephrology–Hemodialysis (SONG-HD) Consensus Workshop on Establishing a Core Outcome Measure for Hemodialysis Vascular Access
Authors: A.K. Viecelli, A. Tong, E. O’Lone, A. Ju, C.S. Hanson, B. Sautenet, J.C. Craig, B. Manns, M. Howell, E. Chemla, L.-S. Hooi, D.W. Johnson, T.Lee, C.E. Lok, K.R. Polkinghorne, R.R. Quinn, T. Vachharajani, R. Vanholder, L. Zuo, C.M. Hawley on behalf of the show SONG-HD Vascular Access Workshop Investigators
DOI: 10.1053/j.ajkd.2017.12.003