Vascular access results from the Dialysis Outcomes and Practice Patterns Study (DOPPS): Performance against Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines

https://doi.org/10.1053/j.ajkd.2004.08.007Get rights and content

Background: The Kidney Disease Outcomes Quality Initiative Guidelines for Vascular Access in hemodialysis patients recommend native arteriovenous (AV) fistulae over AV grafts or catheters for permanent vascular access. They recommend letting fistulae mature ≥1 month before cannulation. Methods: The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides an unparalleled means to examine vascular access practice patterns and guidelines internationally, with particular attention to associations with mortality risk. Results: Most patients in Europe and Japan dialyze through AV fistulae and very few use AV grafts; in the United States, more patients use grafts than fistulae. Patients who receive nephrologic care for over 30 days before starting dialysis have significantly higher chances of commencing via AV fistula. Medical directors of dialysis facilities in the United States commonly prefer grafts; in Europe and Japan, most prefer fistulae. In the United States, there is a relatively long average time between fistula creation and cannulation but significantly worse fistula survival than that seen in Europe. Tunneled catheters pose a higher mortality risk than permanent accesses and are associated with increased risk of failure of a subsequent fistula. The percentage of prevalent patients in the DOPPS countries using catheters has increased in recent years. DOPPS data suggest that performance in some countries falls short of practices achieved in other countries. AV fistula use is low in the United States but has been improving. The trend of increasing use of catheters in most countries is discouraging. Conclusion: The DOPPS will continue to monitor practice trends and explore whether greater application of guidelines will lead to fewer access complications and improved longevity for hemodialysis patients.

Section snippets

Creation and use of permanent vascular access

A significant proportion of patients with end-stage renal disease (ESRD) present for the first time to a nephrologist immediately before requiring dialysis. Moderate differences exist between countries in the percentage of patients presenting late.2 The chances of dialysis commencing via permanent rather than temporary access and via AV fistula rather than graft are significantly higher in patients who receive nephrologic care for more than 30 days before starting dialysis (adjusted odds ratio

Hemodialysis catheter use

Although the use of catheters is discouraged, it is recognized that hemodialysis catheters are unavoidable in some patients. K/DOQI Vascular Access Guideline 51 recommends that, when required, dialysis catheters be inserted in the right internal jugular vein, not in the subclavian vein, because of the risk of subclavian vein stenosis. Performance against this standard for tunneled and untunneled catheters is superior in Europe to the United States, although practice improved in the United

Outcomes associated with the use of hemodialysis catheters

The DOPPS has quantified a number of adverse outcomes that are associated with the use of hemodialysis catheters. After adjusting for patient demographic factors and comorbidities, a significant association has been shown between an increasing percentage of patients within a dialysis facility receiving hemodialysis via a catheter and lower average hemoglobin concentration and higher rates of hospitalization and mortality within that facility.8, 9 At a patient level, the risk of vascular access

Is performance improving toward K/DOQI standards?

Data have been collected for the DOPPS before and since the publication in 1997 and 2000 of the NKF-K/DOQI Clinical Practice Guidelines for Vascular Access. This allows an assessment of the possible impact of these guidelines on hemodialysis practices around the world.

Within the United States, opinion among hemodialysis facility nurse managers has shown a shift from 40% preferring grafts in 1996 to 19995 to only 7% in 2003 (unpublished observations). Correspondingly, the percentage of prevalent

Conclusions

Vascular access provides a lifeline for the hemodialysis patient, and the DOPPS has provided valuable data on this vital aspect of hemodialysis practice. By gathering data from around the world, the DOPPS has shown that performance in some countries falls short of the achieved practice in others. It has also identified areas in which K/DOQI guidelines for vascular access may be refined and performance targets raised. The DOPPS has shown that treatment practices, associated with the opinions and

References (10)

There are more references available in the full text version of this article.

Cited by (193)

  • Outcomes of initial hemodialysis vascular access in patients initiating dialysis with a tunneled catheter

    2019, Journal of Vascular Surgery
    Citation Excerpt :

    These analyses demonstrated that consistently across the outcomes of time to THC removal, likelihood of repeat vascular access and time to repeat vascular access, AVG results in superior outcomes compared with AVF. These results can all likely be attributed to the high AVF maturation failure rate that has been repeatedly reported in the literature.15-17 AVG do not require a maturation period and, in the case of early cannulation grafts, can be punctured as early as 24-48 hours after creation, allowing for earlier THC removal.18,19

View all citing articles on Scopus

The Dialysis Outcomes and Practice Patterns Study is supported by research grants from Amgen and Kirin without restrictions on publications. The NKF gratefully acknowledges the support of Amgen, founding and principal sponsor of K/DOQI. The publication of this supplement was supported by the DOPPS.

View full text