Is the Rule of 6s still the standard for AVF maturation?

Yes. The Rule of 6s (Beathard, 2009) remains the standard clinical assessment for AVF maturation: flow >600 mL/min, diameter >6 mm, depth <6 mm, by 6 weeks. KDOQI 2019 continues to reference this as the primary maturation assessment tool.

Should we use heparin or citrate catheter locks?

KDOQI 2019 recommends either heparin (1000-5000 U/mL) or citrate (4%) for catheter locks. Citrate is preferred in patients with heparin-induced thrombocytopenia (HIT) history. Antibiotic locks should be reserved for documented catheter-related bloodstream infections, not prophylaxis.

How do we handle a clotted AVF?

The protocol includes a thrombosis management algorithm: (1) confirm thrombosis clinically (absent thrill/bruit) and with Doppler, (2) refer to vascular surgery/interventional radiology within 24-48 hours, (3) evaluate for thrombectomy or thrombolysis, (4) place temporary CVC if dialysis cannot be delayed, (5) investigate cause (stenosis, hypotension, dehydration).

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PDF Protocol

Vascular Access Management Protocol for Hemodialysis

Q: Should we use heparin or citrate catheter locks?

KDOQI 2019 recommends either heparin (1000-5000 U/mL) or citrate (4%) for catheter locks. Citrate is preferred in patients with heparin-induced thrombocytopenia (HIT) history. Antibiotic locks should be reserved for documented catheter-related bloodstream infections, not prophylaxis.

Q: How do we handle a clotted AVF?

The protocol includes a thrombosis management algorithm: (1) confirm thrombosis clinically (absent thrill/bruit) and with Doppler, (2) refer to vascular surgery/interventional radiology within 24-48 hours, (3) evaluate for thrombectomy or thrombolysis, (4) place temporary CVC if dialysis cannot be delayed, (5) investigate cause (stenosis, hypotension, dehydration).

Evidence-based vascular access management protocol covering AV fistula creation, maturation monitoring, cannulation techniques, complication management, and surveillance. Based on KDOQI Vascular Access Guidelines (2019 Update) and ESVS clinical practice guidelines.

What's Inside

Access Selection & Planning

9 items

Fistula-first approach, vessel mapping, access type selection criteria (AVF > AVG > CVC), and timing of access creation relative to dialysis initiation.

AV Fistula Maturation

8 items

Maturation timeline (6-8 weeks minimum), physical examination monitoring (rule of 6s), maturation failure predictors, and intervention triggers.

Cannulation Technique

10 items

Rope-ladder vs buttonhole technique, needle size selection, infiltration management, and new access cannulation protocol.

Surveillance & Monitoring

8 items

Monthly access flow measurement, physical examination protocol (look, listen, feel), stenosis detection, and referral criteria.

Complication Management

11 items

Thrombosis, infection, aneurysm, steal syndrome, and venous hypertension — with management algorithms and escalation criteria.

Catheter Management

7 items

CVC insertion site preference (right IJ > left IJ > femoral), exit site care, lock solutions, and catheter-to-AVF transition protocol.

Preview

Protocol Highlights (Sample)

Fistula-first approach: AVF preferred over AVG and CVC for all patients with suitable vessels (KDOQI 2019 Guideline 1.1) — AVF has lowest infection rate and longest survival
Rule of 6s for AVF maturation: flow >600 mL/min, diameter >6 mm, depth <6 mm from skin surface — all criteria met by 6 weeks for successful maturation (Beathard, 2009)
Rope-ladder cannulation recommended as standard technique (rotating puncture sites along the access) — buttonhole technique reserved for self-cannulating patients (KDOQI 2019 Guideline 4.3)
Monthly access surveillance: access flow measurement using ultrasound dilution (Transonic) or Doppler; flow <500 mL/min or >25% decrease from baseline triggers referral for fistulography
Catheter lock: Heparin 1000 U/mL or citrate 4% per facility protocol; antibiotic locks only for documented infection — not for prophylaxis (KDOQI 2019 Guideline 7.3)
CVC-to-AVF transition: AVF cannulated when mature (rule of 6s met); CVC removed after 2 successful AVF dialysis sessions with adequate blood flow (>300 mL/min)

Measurable Impact

Protocol checkpoints

6-8 wks

AVF maturation timeline

<500 mL/min

Access flow referral threshold

KDOQI

2019 guidelines aligned

Based on Published Standards

KDOQI Clinical Practice Guidelines for Vascular Access (2019 Update)

ESVS Clinical Practice Guidelines for Vascular Access (2018)

Beathard — Physical Examination of the Dialysis Access (Seminars in Dialysis, 2009)

NKF-KDOQI — Clinical Practice Guidelines for Vascular Access (2006, superseded by 2019)

Indian Society of Nephrology (ISN) — Dialysis Practice Guidelines

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What's Inside

Access Selection & Planning

9 items

Fistula-first approach, vessel mapping, access type selection criteria (AVF > AVG > CVC), and timing of access creation relative to dialysis initiation.

AV Fistula Maturation

8 items

Maturation timeline (6-8 weeks minimum), physical examination monitoring (rule of 6s), maturation failure predictors, and intervention triggers.

Cannulation Technique

10 items

Rope-ladder vs buttonhole technique, needle size selection, infiltration management, and new access cannulation protocol.

Surveillance & Monitoring

8 items

Monthly access flow measurement, physical examination protocol (look, listen, feel), stenosis detection, and referral criteria.

Complication Management

11 items

Thrombosis, infection, aneurysm, steal syndrome, and venous hypertension — with management algorithms and escalation criteria.

Catheter Management

7 items

CVC insertion site preference (right IJ > left IJ > femoral), exit site care, lock solutions, and catheter-to-AVF transition protocol.

Preview

Protocol Highlights (Sample)

Fistula-first approach: AVF preferred over AVG and CVC for all patients with suitable vessels (KDOQI 2019 Guideline 1.1) — AVF has lowest infection rate and longest survival
Rule of 6s for AVF maturation: flow >600 mL/min, diameter >6 mm, depth <6 mm from skin surface — all criteria met by 6 weeks for successful maturation (Beathard, 2009)
Rope-ladder cannulation recommended as standard technique (rotating puncture sites along the access) — buttonhole technique reserved for self-cannulating patients (KDOQI 2019 Guideline 4.3)
Monthly access surveillance: access flow measurement using ultrasound dilution (Transonic) or Doppler; flow <500 mL/min or >25% decrease from baseline triggers referral for fistulography
Catheter lock: Heparin 1000 U/mL or citrate 4% per facility protocol; antibiotic locks only for documented infection — not for prophylaxis (KDOQI 2019 Guideline 7.3)
CVC-to-AVF transition: AVF cannulated when mature (rule of 6s met); CVC removed after 2 successful AVF dialysis sessions with adequate blood flow (>300 mL/min)

Measurable Impact

Protocol checkpoints

6-8 wks

AVF maturation timeline

<500 mL/min

Access flow referral threshold

KDOQI

2019 guidelines aligned

Based on Published Standards

KDOQI Clinical Practice Guidelines for Vascular Access (2019 Update)

ESVS Clinical Practice Guidelines for Vascular Access (2018)

Beathard — Physical Examination of the Dialysis Access (Seminars in Dialysis, 2009)

NKF-KDOQI — Clinical Practice Guidelines for Vascular Access (2006, superseded by 2019)

Indian Society of Nephrology (ISN) — Dialysis Practice Guidelines