The 2019 proposed National Kidney Foundation’s (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) recommends a regular physical examination by a knowledgeable and experienced health practitioner to detect flow dysfunction. The proposed Guidelines cite five references to support their position.^1-5 Asif’s 2005 reference “Accuracy of physical examination in the detection of arteriovenous fistula stenosis” from the Miller School of Medicine at the University of Miami was referenced several times. Two other studies^3-4 also originated at that same institution. All four studies^1-4 cited the use of interventionalists, interventionalist fellows, or physicians trained in vascular access physical examinations to monitor for and detect AV-access flow dysfunction.

None of the references evaluated the physical examination skills of Nephrology Patient Care Technicians (PCTs), the persons who, in the US, are most frequently charged with cannulation of the access and care of the patients. The guidelines recommendation came from the experience and physical examination skills of highly trained physicians rather than those at the forefront of hemodialysis process of care, who see and care for their dialysis patients on a daily and weekly basis.

Can this recommendation, therefore, be feasible for PCTs, nephrology trainees, and nurses, who, in practice, would be the ones conducting the physical exam?

References:

1 Asif A, Leon C, Orozco-Vargas LC, Krishnamurthy G, Choi KL, Mercado C, Merrill D, Thomas I, Salman L, Artikov S, Bourgoignie JJ, "Accuracy of physical examination in the detection of arteriovenous fistula stenosis,” Clin J Am Soc Nephrol. 2007 Nov;2(6):1191-4. (142 consecutive patients referred for an arteriovenous fistula dysfunction were examined to detect stenotic lesions and were compared with angiography. The study demonstrated that physical examination by trained interventionalists can accurately detect and localize stenoses in a great majority of arteriovenous fistulas.)

2 Campos RP, Chula DC, Perreto S, Riella MC, do Nascimento MM, “Accuracy of physical examination and intra-access pressure in the detection of stenosis in hemodialysis arteriovenous fistula. Semin Dial. 2008 May-Jun;21(3):269-73. (Abnormalities of pulse and thrill were used as diagnostic tools for the detection of stenosis in 84 patients by an interventional nephrologist. The accuracy for physical examination (PE) and intra-access pressure was 88% and 71%, respectively. PE proved to be an accurate method for the diagnosis of stenosis and should be part of all surveillance protocols of stenosis detection in AVF.)

3 Leon C, Asif A. “Physical examination of arteriovenous fistulae by a renal fellow: does it compare favorably to an experienced interventionalist?” Semin Dial. 2008;21(6):557-560. (After a nephrolpgy fellow had been trained for one month in physical examination, there was insignificant differences in their and an inventionalist’s physical examination skills. The conclusion suggests that nephrology training programs should place more emphasis on this aspect of vascular access education.) 

4 Leon C, Orozco-Vargas LC, Krishnamurthy G, et al. “Accuracy of physical examination in the detection of arteriovenous graft stenosis,” Semin Dial. 2008;21(1):85-88. (43 consecutive cases referred for an arteriovenous graft dysfunction were examined by an experienced interventionalst. The study demonstrated that physical examination can assist in the detection and localization of stenoses in arteriovenous grafts.)

5 Coentrão L, Turmel-Rodrigues L, “Monitoring dialysis arteriovenous fistulae: it's in our hands,”

J Vasc Access. 2013 Jul-Sep;14(3):209-15. (Review of the basics and drawbacks of physical examination for dialysis arteriovenous fistulae and to provide with its diagnostic accuracy in the detection of arteriovenous fistula dysfunction, based on current published literature.)