Vascular Access for Hemodialysis

1 Over 90% of these patients received hemodialysis, necessitating an arteriovenous fistula (AVF), arteriovenous graft (AVG), or tunneled catheter (TC) to provide access to high-volume blood flow. Adequate performance by any of these access options is required for successful hemodialysis, and creating and maintaining functional access for the large and growing number of dialysis patients poses economic challenges. Although in 2005, patients with end-stage renal disease (ESRD) represented only 1.2% of the Medicare population, 8.2% of Medicare expenditures ($17 billion) were asso - ciated with their care. This 6.8-fold overrepresentation in cost places ESRD as a disease group ranking higher than congestive heart failure (CHF; 3-fold), chronic kidney disease (CKD; 2.9-fold), or diabetes (1.7-fold). 1 Expenditures for vascular access placement and access complications alone were over $1.5 billion. One may speculate that these costs will rise out of proportion, since diabetes and hypertension both affect the peripheral vascu - lature with potential detriment to long-term access options and increased vascular access complications. In the US, vascular access care is the responsibility of numerous groups. General, vascular, or transplant surgeons place AVFs, AVGs, and TCs, and often perform endovas - cular procedures to treat access complications. Interventional radiologists are predomi - nantly concerned with placement of TCs and the endovascular treatment of access complications (eg, stenoses and thromboses). More recently, nephrologists with training in endovascular or surgical procedures have begun to provide access care to dialysis patients. With so many physicians contributing to the management of vascular access, important questions are raised about the quality of care delivered to patients with ESRD. Unfortunately, prospective randomized controlled studies in this field are rare, often leaving physicians to rely on opinion and small retrospective trials. The challenge for practicing nephrologists is to become knowledgeable in conducting hemodialysis care for their patients. This issue of Nephrology Rounds provides the knowledge base for under - standing vascular access decisions and procedures. HHistory of vvascular aaccess