Guidelines for Venous Access in Patients with Chronic ...

Guidelines for Venous Access in Patients with

Chronic Kidney Disease

A Position Statement from the American Society of

Diagnostic and Interventional Nephrology1

Clinical Practice Committee and the Association for

Vascular Access2

Jeffrey Hoggard,* Theodore Saad,? Don Schon,? Thomas M. Vesely,¡ì and Tim Royer¨C

*Eastern Nephrology Associates, P.L.L.C., Greenville, North Carolina, ?Nephrology Associates, P.A.,

Department of Medicine, Nephrology Christiana Care Health System, Newark, Delaware, ?Arizona Kidney

Disease and Hypertension Surgery Center, Phoenix, Arizona, ¡ìVascular Access Center, Frontenac, Missouri,

and ?VA Puget Sound Health Care System, Seattle, Washington

ABSTRACT

At the time of hemodialysis vascular access evaluation, many

chronic kidney disease patients already have iatrogenic injury

to their veins which impedes the surgical construction of an

arteriovenous ?stula (AVF). Achieving the important goal of a

greater prevalence of arteriovenous ?stulae in the US hemodialysis population will require identi?cation of those patients

prior to reaching end-stage renal disease and an educational

and procedural system for preserving their veins.

The use of venous access devices is ubiquitous in modern medicine. Establishing and maintaining intravenous

access for patients with chronic kidney disease (CKD)

necessitate special considerations unique to this patient

population. In patients with CKD preservation of the

integrity of peripheral and central veins is of vital importance for future hemodialysis access. Cannulation of

veins and insertion of venous access devices have potential to injure the veins and thereby incite phlebitis, sclerosis, stenosis or thrombosis. The creation of a high

quality arteriovenous ?stula (AVF) may become dif?cult or impossible in the presence of prior venous injury.

The purpose of these guidelines is twofold. First, they

provide criteria for early identi?cation of CKD patients

who are likely to need a hemodialysis graft or ?stula in

the future. Secondly, these guidelines provide an algorithm for delivery of optimal venous access in these

high-risk patients. Ultimately, this requires an integrated

team approach involving the physician requesting

venous access, the nurses caring for the patient, the vascular access nurses responsible for placement of peripheral venous access, vascular access experts responsible

for image-directed placement of venous access (interventional radiologists, nephrologists, or surgeons), the clinical nephrologist managing the patient¡¯s CKD, and the

vascular surgeon responsible for creating arteriovenous

hemodialysis accesses. Optimal venous access practice

and management for the CKD patient is likely best

achieved by establishing consensus Policy and Procedure

at each institution.

1

ASDIN Clinical Practice Committee members: Steve Ash,

M.D., Chair, Gerald Beathard, M.D., Jeffrey Hoggard, M.D.,

Terry Litchfield, M.P.A., Dr.PH., George Nassar, M.D., Tony

Samaha, M.D., Don Schon, M.D., Vijay Sreenarasimhaiah,

M.D., Tom Vesely, M.D., Monnie Wasse, M.D.

Background

Vascular Access for Hemodialysis

The autogenous AVF is the preferred form of vascular access for hemodialysis, delivering superior patency

with lower morbidity, hospitalization, and costs relative

to prosthetic grafts or hemodialysis catheters (1¨C6). For

these reasons, the nephrology community has implemented a nationwide agenda to increase the creation of

autogenous ?stulae in hemodialysis patients. The

National Kidney Foundation ¨C Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) publishes

2

AVA members: Denise Macklin, RNBC, Kathy McHugh, RN,

BSN, Tim Royer, BSN, CRNI, Kelli Rosenthal, MS, RN, BC, CRNI,

ANP, APRN, BC

Address correspondence to: Jeffrey Hoggard, MD, 1776

Blue Banks Farm Rd, Greenville, NC 27834, or email: jhoggard@.

Seminars in Dialysis¡ªVol 21, No 2 (March¨CApril) 2008

pp. 186¨C191

DOI: 10.1111/j.1525-139X.2008.00421.x

186

GUIDELINES FOR VENOUS ACCESS IN PATIENTS

speci?c guidelines relative to creation and management

of hemodialysis vascular accesses (7). More recently, the

Centers for Medicare and Medicaid Services (CMS)

along with the regional End-Stage Renal Disease

(ESRD) Networks and the clinical nephrology community have developed and promoted the National Vascular Access Improvement Initiative (NVAII) called

¡®¡®Fistula First Breakthrough,¡¯¡¯ with the speci?c goal of

promoting more autogenous ?stulae in hemodialysis

patients. By 2009, the goal is to achieve a 67%

prevalence rate of autogenous ?stulae in hemodialysis

patients (8). Ultimately, this strategy to create more

functional ?stulae is critically dependent on the availability and condition of the patient¡¯s central and

peripheral veins. Frequent venipuncture and the indiscriminate use of peripheral intravenous lines, peripherally inserted central catheters (PICCs) or central venous

catheters can damage veins, impair venous circulation

and jeopardize future ?stula construction or function.

Therefore, to preserve peripheral and central veins for

future hemodialysis vascular access it is of paramount

importance that CKD patients achieve early protection

of their critical venous real estate. This important concept has been emphasized in editorials by Trerotola (9),

Saad and Vesely (10), and more recently by McLennan

(11).

Venous Injury

The injurious effects of phlebotomy and peripheral

and central venous catheters include phlebitis, venous

sclerosis, stenosis, and thrombosis. Vascular damage

may occur early, at the time of catheter insertion, or the

injury may be progressive if the catheter remains in the

vein for an extended period of time (12). Forauer and

colleagues reported their ?ndings from an autopsy

study; these investigators described pathological changes

of endothelial denudation associated with short-term

central catheter use. With long-term catheter use, there

was vein wall thickening, increased number of smooth

muscle cells, and focal catheter attachments to the vein

wall with thrombus and collagen (13). Ducatman et al

performed an autopsy study of 141 patients with central

venous catheters and reported that 32% had pericatheter thrombus in the brachiocephalic veins or superior

vena cava within 2 weeks after catheter insertion (14). In

the majority of previously published studies, including

the classic study of PICCs by Grove and Pevec, followup imaging studies were only performed in symptomatic

patients (15). A more accurate assessment of venous

injury would require thorough venographic imaging

both before and after placement of the venous catheters

in all patients. Allen et al. used contrast venography at

the time of initial PICC placement, and then again when

a subsequent PICC was placed in the same patients (16).

These investigators reported that 23.3% of patients

developed venous thrombosis after initial PICC placement. When all subsequent PICC placements were

included for patients who underwent multiple PICC

insertion procedures, the rate of thrombosis increased to

38%. In this study, the rate of thrombosis in the cephalic

vein was particularly high with 57% of patients develop-

187

ing thrombosis after PICC placement. In a similar study,

Gonsalves et al. reviewed venographic studies that were

performed both before and after insertion of PICCs in

150 patients to determine the incidence of central venous

stenosis or occlusion (17). These investigators reported

that 7.5% of patients with previously normal central

venograms developed subsequent venographic abnormalities after PICC placement; 4.8% developed central

venous stenosis and 2.7% had central venous occlusion.

Abdullah et al performed venography at the time of

PICC removal in a small prospective study and documented venous occlusion in 38.5% of 26 patients (18).

Central venous catheters inserted into the subclavian

vein can cause stenosis and thrombosis. Hernandez et al.

used serial venographic studies to evaluate the long-term

effects of subclavian vein catheters in 42 patients (19). At

the time of catheter removal, 45% of patients had stenoses and 7% had total thrombosis of the subclavian

vein. In a retrospective study of 279 central venous catheters in 238 patients, Trerotola et al. reported that catheter-related venous thrombosis occurred in 13% of

patients with subclavian vein catheters, compared with

3% of patients with internal jugular vein catheters (20).

The mean time to thrombosis was 36 days for subclavian catheters and 142 days for internal jugular vein

catheters. Similarly, Bambauer reported an incidence of

thrombosis or stenosis in 8% of patients receiving subclavian vein catheters and only 0.3% of patients with

internal jugular vein catheters (21). The NKF-KDOQI

Guidelines recommend the use of internal jugular vein

and avoidance of the subclavian vein and PICCs for

venous access based on this data.

Guidelines for Venous Access in Patients with

Chronic Kidney Disease

A. Identify CKD patients who may need hemodialysis treatment in the future.

1. Patients with CKD Stages-3, 4 or 5. This

includes stage 5 CKD patients currently receiving hemodialysis or peritoneal dialysis.

2. Patients with a functional kidney transplant.

B. Venous Access for stage 3¨C5 CKD patients.

1. The dorsal veins of the hand are the preferred

location for phlebotomy and peripheral venous

access.

2. The internal jugular veins are the preferred

location for central venous access.

3. The external jugular veins are an acceptable

alternative for venous access.

4. The subclavian veins should not be used for central venous access.

5. Placement of a PICC should be avoided.

C. Implementation of Policy and Procedure for

Venous Access in CKD patients.

Policy and Procedure should be established to allow

members of the vascular access team to assess and provide recommendations for vascular access issues for

stage 3¨C5 CKD patients.

188

Hoggard et al.

Discussion

A. Identify CKD patients who may need hemodialysis treatment in the future.

1. Patients with CKD Stages-3, 4 or 5. This

includes stage 5 CKD patients currently receiving hemodialysis or peritoneal dialysis.

2. Patients with a functional kidney transplant.

Rationale

Identifying those patients at risk for future hemodialysis is the ?rst step of a care path designed to protect venous anatomy. An isolated serum creatinine is a

notoriously inaccurate measure of kidney function.

The NKF recommends calculating an estimated glomerular ?ltration rate (eGFR) in all CKD patients to

assess and stage their renal insuf?ciency (7) (see

Table 1). Using the modi?ed Levey formula of the

Modi?cation of Diet in Renal Disease (MDRD) equation one can easily calculate an eGFR standardized

for body surface area with the following four variables:

serum creatinine, age, sex, and race (22) (see Table 2).

The NKF and National Kidney Disease Education

Program recommend that all clinical laboratories provide an eGFR value when a serum creatinine is

ordered (23). The Cockcroft-Gault formula, a method

of estimating creatinine clearance standardized for

weight, is an alternative method of evaluating renal

function (see Table 2). Personal digital assistants and

websites routinely provide easy calculator tools for

both these formulas. The value of these equations in

estimating renal function as well as the limitations

have been published (24). Lastly, in the absence of an

eGFR or creatinine clearance an elevated serum

creatinine of greater than 2.0 mg ? dl would be a

conservative indication to restrict venous access. This

recommendation to evaluate renal function with an

eGFR is not limited to the assessment of CKD

patients needing venous access. Pharmacy, radiology,

and cardiology organizations are routinely adopting

TABLE 1. Classi?cation of Chronic Kidney Disease

Stage

I

II

III

IV

V

Description

¡®¡®Normal¡¯¡¯ renal function

¡®¡®Mild¡¯¡¯ renal dysfunction

¡®¡®Moderate¡¯¡¯ renal dysfunction

¡®¡®Severe¡¯¡¯ renal dysfunction

¡®¡®End-Stage¡¯¡¯ renal disease

eGFR

(ml ? min ? 1.73 m2)

>90

60¨C89

30¨C59

15¨C29

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