Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): performance against kidney disease otucomes quality initiative (K/DOQI) clinical practice

Abstract

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.