Vascular access for hemodialysis

Access to large blood vessels capable of providing rapid extracorporeal blood flow is essential for maintenance hemodialysis. Access to the circulation is still best provided by native AV fistulas, but AV grafts offer an acceptable alternative. Efforts at encouraging earlier referrals to nephrologists likely will facilitate preservation of vascular access sites and will allow AV fistulas to be placed in a higher percentage of cases; the latter goal was one of the primary recommendations of the DOQI [7]. Recent data from the DOPPS study confirm these predictions [6]. Patients referred early to a nephrologist are 4 times more likely to have a permanent access placed prior to starting dialysis and are 9 times more likely to have an AV fistula [6]. Increasing the percentage of native AV fistulas among dialysis patients in the US is an enormous step forward in decreasing patient morbidity and cost to the ESRD system. A goal of 40% AV fistulas in the US hemodialysis population is attainable over the next 3 years if patients are referred to nephrologists early. I would argue (as did DOQI) that such referral should occur when the serum creatinine concentration reaches 3 4 mg/dl. In addition, strategies for prospective detection of hemodynamically significant outflow stenoses, when combined with pro-active correction of this offending lesion, significantly improve access patency and should be universally adopted. The morbidity and costs associated with maintenance of vascular access constitute an enormous burden both for our patients and for the end-stage renal disease system. Significant advances have occurred in our understanding of AV access failure, and our therapeutic techniques have improved significantly. The ideal approach, however, is prevention of the endothelial and fibromuscular hyperplasia that leads to the vast majority of access failures. Vigorous basic science investigation of vascular biology and active clinical investigation of medical and surgical therapy are required to eliminate this bane of our patients' existence.