Barriers to optimal vascular access for hemodialysis.

Vascular access is the Achilles heel for hemodialysis (HD). An arteriovenous fistula (AVF), considered the optimal access for HD, rather than a graft or central venous catheter (CVC) caused the "Fistula First" initiative to dominate quality assessment. However, this initiative had the unintended consequence of increasing the proportion of less desirable catheters, leading to "Fistula First, Catheter Last". But as the end-stage kidney disease (ESKD) population expanded with aging, sicker patients, individual assessment of the appropriate access changed the paradigm to KDOQI's "Patient First: ESKD Life-Plan" to attain the "right access, in the right patient, at the right time, for the right reasons". However, such a goal has proved elusive because the optimal vascular access does not currently exist. Thus, ESKD care providers attempting to offer the "right access" must weigh the barriers to achieving the most optimal access to suit each of their HD patients. The barriers are based on shortcomings related specifically to each of the three vascular accesses and to characteristics of each ESKD patient's demographics, physical factors, quality of life, and cost considerations. This article will describe these barriers so that clinicians caring for ESKD patients initiating or receiving HD provide the most optimal vascular access for that specific patient.