18-04-16

1

Preliminary Update of the KDOQI Vascular Access Guidelines 2018

Charmaine Lok, MD Professor of Medicine, University of Toronto UCSF Vascular Symposium 2018 April 19, 2018 San Francisco

So What’s New: The Outline

•  The Process o  Building blocks and development over time o  Timelines

•  Who’s involved •  Where we’re at and next steps •  What it looks like

•  The Statements •  The Concepts

The Process

Older Guidelines

Great necessary foundation

Timelines

Scope of Work

Literature review

Data Retrieval & Analysis

Interpretation & Clinical relevance

Quality of Evidence

Strength of Recommendation

Review & Synthesis

Internal Review

External Review

Implementation

Evidence Review Team (ERT)

KDOQI Workgroup

ERT Data ERT has high standards!

18-04-16

2

KDOQI “Statement”

4 Kinds: “KDOQI recommends” “KDOQI suggests” “There is inadequate evidence…” “In the opinion of the KDOQI Workgroup…”

Based on ERT extracted data, meeting their

search, extraction and

analysis criteria

Data available in the literature but did not meet ERT criteria, retrieved by workgroup and extensively discussed

ESRD

OUR PATIENTS

Photos taken with consent, permission to share given

New Concepts

Recommendation for Vascular Access for Hemodialysis – Looks the Same??

HD

ESKD Life-Plan

Remember: CKD is a continuum

Stages: I II III IV V RRT

Modality (HD/PD/

Transplant)

RRT Modality

(HD/PD/Transplant)

RRT Modality

(HD/PD/Transplant)

ESKD is part of the CKD continuum

Within ESKD, a patient is anticipated to have a continuum of therapies to help

optimize their life - their ESKD Life-Plan

PD Transplant HD

Our Approach •  Focus on a “Life-Plan” for a Patient’s

Dialysis Access Needs

PD 1 Transplant 2 HD: Fistula 3

Nocturnal Home

HD: Graft 4

Example only:

New Philosophy

RIGHTACCESSRIGHTPATIENTRIGHTTIME

RIGHTREASONS

18-04-16

3

How?.....P-L-A-N

• Patient

• Life-Plan

• Access • Needs

? ? • Patient

• Life-Plan

• Access • Needs

How?.....P-L-A-N

• Patient

• Life-Plan

• Access • Needs

Patient First

What is the Patient’s ESKD Life-Plan?

How?.....P-L-A-N

• Access • Needs

What is the Patient’s Access Creation Plan

What access, where, when, by whom?

How?.....P-L-A-N

• Access • Needs

What are the remedial measures when the access becomes problematic?

What is the Patient’s Access Contingency Plan

How?.....P-L-A-N

• Access • Needs

What access is next when the current one fails?

What is the Patient’s Access Succession Plan

How?.....P-L-A-N

ü  Patient

ü  Life-Plan

ü  Access ü  Needs

18-04-16

4

Allied Health

Epidemiology & Statistics

Workgroup Members •  Nephrology

o  Michael Allon o  Timmy Lee o  Charmaine Lok o  Louise Moist

Workgroup

Nephrology

Surgery Interventional

•  Surgery o  Marc Glickman o  Thomas Huber o  Suren Shenoy

•  Interventional o  Ken Abreo o  Arif Asif o  Dheeraj Rajan o  Tushar Vaccharajani o  Alex Yevzlin

•  Allied Health & Epi o  Brad Astor o  Janet Graham o  Cindy Roberts

•  Pediatric Nephrology o  Rudy Valentini

Evidence Review Team

•  Timothy J. Wilt, MD, MPH •  Nancy Greer, PhD •  Michelle Brasure, PhD, MSPH •  Areef Ishani, MD, M.C.R. •  Yelena Slinin, MD, M.Sc. Minnesota Evidence Review Team: Minneapolis VA Health Care System University of Minnesota Schools of Medicine University of Minnesota School of Public Health

THANK YOU FOR YOUR ATTENTION