Advocate for Surveillance in the new 2019 KDOQI Guidelines

The proposed 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines are now open for review with comments accepted through June 7, 2019. Transonic hopes hemodialysis stakeholders who have pre-registered to review the proposed Guidelines will submit their comments by the June 7th deadline.

Objective Versus Subjective; Quantitative Versus Qualitative

The proposed Guidelines’ goal is to give hemodialysis patients “right access, in the right patient, at the right time, for the right reasons." They markedly deemphasize the value of objective access flow surveillance and underscore the value of subjective, physical examination of a vascular access. This is alarming! By moving away from quantitative tools like Transonic measurements to qualitative physical examinations, hemodialysis patients are left at the mercy of their practitioner’s observational skills to determine if they have is a flow limiting stenosis. Moreover,

• This physical monitoring recommendation disregards the dialysis staffing crisis in the US where much dialysis patient care is performed by technicians and where staff turnover is high. Listening, looking and feeling a fistula will be the primary test.
• It also disregards the American for-profit healthcare system. If surveillance is not mandated, will it NOT be in the shareholder’s interest to allow doctors to purchase additional equipment.

Separating the Wheat from the Chaff

Secondly, the proposed Guidelines’ group all surveillance technologies together in one sweeping recommendation that doesn’t support surveillance, rather than separating the wheat from the chaff and recognizing ultrasound dilution (Transonic) technology (the recognized gold standard) as singularly able to accurately track the functionality of the access and whether an access can deliver adequate blood flow to support hemodialysis. Randomized controlled trials (RCTs) have confirmed this value of flow-based (ultrasound dilution) AV-access surveillance.^1,2

Interventions

Another significant change in the Guidelines is to require clinical indicators before pre-emptive angioplasty or surgical intervention is performed. Transonic measurements, trended over time, combined with angiograms and physical exams, have historically provided objective data to help determine whether angioplasty was called for. Angiograms alone cannot determine whether a stenosis is flow-limiting or not. Removing surveillance, the only objective, quantitative tool in the nephrologist’s arsenal that provides a true flow rate in the access, will certainly make it harder for nephrology providers to quantify whether angioplasty is warranted and deliver the best care.

To Measure Is to Know!

Advocate for Transonic surveillance.

1 Aragoncillo I et al, “Adding access blood flow surveillance reduces thrombosis and improves arteriovenous fistula patency: a randomized controlled trial,î J Vasc Access. 2017; 18(4): 352-358. (Transonic Reference # HD11190A)

2 Tessitore N et al, “Adding access blood flow surveillance to clinical monitoring reduces thrombosis rates and costs, and improves fistula patency in the short term: a controlled cohort study.” Nephrol Dial Transplant 2008 23:3578-3584. (Transonic Reference # HD7639A)