Incident Dialysis Access in Patients With End-Stage Kidney Disease: What Needs to Be Improved.

The initiation of dialysis is a challenging time of transition for patients, families, and their supporters. Patients with exposure to a comprehensive chronic kidney disease clinic may have had education and subsequent decision making regarding dialysis modality and access; however, many patients with or without prior education will require an urgent start to dialysis, requiring quick decisions regarding dialysis modality and access. In many countries, hemodialysis (HD) using a central venous catheter (CVC) is the most common initial renal replacement modality and dialysis access. Multiple factors, both remedial and nonremedial, contribute to this including late referral, rapid decrease in kidney function, delay in delivery or acceptance of education, and decision making and other system delays. Recent use of urgent peritoneal dialysis as the initial dialysis modality has resulted in decreased exposure to CVCs and in-center HD. This article addresses the current state of incident dialysis access, recent trends toward urgent peritoneal dialysis start, and opportunities to avoid the use of CVCs for HD when appropriate, with a focus on considering dialysis access as a critical component of the end-stage kidney disease life-plan, which requires consideration of future modalities and access when making the choice of the initial dialysis access.