Vascular access surveillance: case study of a false paradigm

Area of Science:

• Nephrology
• Vascular Surgery
• Health Policy

Background:

• Clinical practice guidelines often incorporate established paradigms, which are shared beliefs within a field.
• The National Kidney Foundation Kidney Disease Outcomes Quality Initiative recommends routine surveillance for hemodialysis arteriovenous vascular access stenosis.
• This recommendation is based on the paradigm that surveillance and stenosis correction improve access outcomes.

Purpose of the Study:

• To critically evaluate the validity of the current hemodialysis vascular access surveillance paradigm.
• To assess whether existing surveillance methods provide significant benefits for vascular access outcomes.

Main Methods:

• A literature review of published vascular access studies was conducted.
• The World Health Organization (WHO) criteria for evaluating screening tests were applied.
• The WHO criteria assess four components: undesired condition, screening test, intervention, and desired outcome.

Main Results:

• Application of WHO criteria indicated that current vascular access surveillance practices fail all four components.
• The review suggests that surveillance, as currently practiced, provides little to no significant benefit.
• These findings challenge the established paradigm of routine surveillance for hemodialysis vascular access.

Conclusions:

• The current paradigm of routine hemodialysis vascular access surveillance appears to be a false paradigm.
• Rigorous criteria are essential when developing clinical guidelines to prevent the adoption of invalid practices.
• Regulatory bodies can drive necessary paradigm shifts, particularly when cost and safety are considered.