Dialysis Access Problem
Suspected dysfunction of AVF, AVG, or catheter
All Pathways
Vascular SurgeryManagement
Dialysis Access Dysfunction (KDOQI 2019)
Dialysis Access Dysfunction (KDOQI 2019): Dialysis Access Problem → Access Type → AVF Assessment → Type of Dysfunction → Stenosis (Non-thrombosed).
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Decision Access Type
Identify the type of dialysis access
- AVF
03Action AVF Assessment
Arteriovenous fistula evaluation
- Physical exam: thrill, bruit, arm swelling
- Access flow measurement (ultrasound dilution)
- Elevated venous pressures during dialysis
- Prolonged bleeding post-dialysis (>20 min)
- Recirculation >10%
04Decision Type of Dysfunction
AVF/AVG dysfunction pattern
- Low flow/high pressure
05Action Stenosis (Non-thrombosed)
Venous or arterial stenosis
- Access flow <600mL/min or >25% decline
- Elevated venous pressures
- Difficult cannulation
- Arm swelling (central stenosis)
- Refer for fistulogram
06Action Fistulogram/Intervention
Diagnostic and therapeutic procedure
- Percutaneous access under fluoroscopy
- Map entire circuit: artery → vein → central
- Stenosis >50% with clinical signs = treat
- PTA (balloon angioplasty) first-line
- Drug-coated balloon for recurrence
- PTA success
07Action Access Salvage Outcome
Post-intervention assessment
- Clinical improvement: thrill restored
- Access flow >600mL/min
- Adequate dialysis clearance
- Plan surveillance protocol
- Consider secondary patency rates
- Salvaged
08Outcome Functional Access Restored
Continue dialysis; surveillance every 3 months
- Unsalvageable
09Outcome New Access Required
Plan new AVF/AVG; temporary catheter if needed
- PTA fails
10Action Surgical Revision
When endovascular fails or unsuitable
- Thrombectomy (open or hybrid)
- Patch angioplasty for focal stenosis
- Jump graft for access salvage
- New access creation if unsalvageable
- Consider prior to multiple PTA failures
- Path rejoins step 07Shared downstream outcome
- No thrill/bruit
11Action Thrombosis
Acute access occlusion
- Absent thrill and bruit
- Unable to aspirate blood
- URGENT: intervene within 24-48h
- Options: surgical vs endovascular
- Temporary catheter may be needed
- Endovascular
- Path rejoins step 06Shared downstream outcome
- Surgical
- Path rejoins step 10Shared downstream outcome
- New AVF not usable
12Action Maturation Failure
AVF not usable at 6-8 weeks
- Vein diameter <6mm
- Flow <600mL/min
- Depth >6mm from skin
- Rule of 6s not met
- Fistulogram to identify cause
- Path rejoins step 06Shared downstream outcome
- AVG
13Action AVG Assessment
Arteriovenous graft evaluation
- Similar to AVF assessment
- Higher thrombosis risk than AVF
- Pseudoaneurysm evaluation
- Graft infection signs (warmth, erythema)
- Access flow trending <600mL/min
- Path rejoins step 04Shared downstream outcome
- Catheter
14Action Catheter Assessment
Central venous catheter evaluation
- Blood flow rates achieved
- Exit site: drainage, erythema, tenderness
- Tunnel tract infection signs
- Fibrin sheath suspected if positional
- Fever or bacteremia workup
15Decision Catheter Problem Type
Identify catheter issue
- Infection
16Action Catheter Infection
Exit site, tunnel, or bloodstream
- Exit site: topical treatment, antibiotics
- Tunnel infection: catheter removal
- CRBSI: blood cultures, empiric antibiotics
- Vanc + aminoglycoside or ceftazidime
- Remove catheter if tunnel/severe infection
- Path rejoins step 07Shared downstream outcome
- Malfunction
17Action Catheter Malfunction
Mechanical/flow problems
- Fibrin sheath: tPA lock or stripping
- Malposition: fluoroscopic repositioning
- Thrombotic occlusion: tPA instillation
- Exchange over wire if needed
- Consider catheter replacement
- Path rejoins step 07Shared downstream outcome
Guideline Source
KDOQI 2019 Clinical Practice Guideline for Vascular Access
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not cover initial access creation/planning
- Assumes established dialysis patient
- Catheter-related bloodstream infection requires ID consult
- Local expertise and facility resources vary
- Does not address peritoneal dialysis access
Applicable Regions
USEUGlobal
EU: EBPG guidelines similar; local nephrology protocols vary
US: KDOQI 2019 is standard; CMS ESRD QIP measures apply
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Dialysis Access Dysfunction (KDOQI 2019)?
The Dialysis Access Dysfunction (KDOQI 2019) is a management clinical algorithm for Vascular Surgery. It provides a structured decision tree to guide clinical decision-making, based on KDOQI 2019 Clinical Practice Guideline for Vascular Access.
What guideline is the Dialysis Access Dysfunction (KDOQI 2019) based on?
This algorithm is based on KDOQI 2019 Clinical Practice Guideline for Vascular Access (DOI: 10.1053/j.ajkd.2019.12.001).
What are the limitations of the Dialysis Access Dysfunction (KDOQI 2019)?
Known limitations include: Does not cover initial access creation/planning; Assumes established dialysis patient; Catheter-related bloodstream infection requires ID consult; Local expertise and facility resources vary; Does not address peritoneal dialysis access. Individual patient factors may require deviation from these recommendations.
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