History and Physical Examination for Access Planning

The first step in evaluating a patient for dialysis access is to obtain a history and physical examination, obviously focusing on factors relevant to access creation and how this will impact their lives. Issues such as low educational and socioeconomic status, poor prior health care, barriers to understanding the issues at hand, and language barriers obviously should be considered early in the evaluation process. Importantly, the provider should not assume that a detailed discussion of this issue (including decision making with regard to hemodialysis, peritoneal dialysis, or transplant) has taken place, particularly if the patient with a catheter has been referred by a dialysis center. Both history and physical examination can be conducted in a traditional fashion, but it is also useful to evaluate the patient in terms of the four critical issues necessary for proper hemodialysis: Inflow, conduit, tunnel, and outflow. A standardized process, form, or macro is obviously optimal for complete data collection and review. Once this process has taken place, the next steps are detailed ultrasonic evaluation of the limb in patients needing hemodialysis followed by decision making, both covered in the two subsequent chapters.