The Difficult Access Patient

It is imperative that a patient with a difficult access does not become a “difficult access patient.” The former is purely technical, while the latter involves psychological issues and is of value to no one. Access problems can arise from problems with inflow, often (but not always) correctable, outflow (much more easily treatable today with modern equipment and techniques), conduit (correctable by the use of prosthetic), or tunnel issues (usually correctable by surgeon training and judgement). Physiologic issues such as poor cardiac function, pulmonary hypertension, chronic hypotension, hypercoagulable states, and the like, also likely affect outcomes, but in most cases hard data are lacking. These factors, in general, should lead to a more aggressive use of AVFs, and in particular lower flow options, but also are sometimes markers of such short life expectancy that consideration of catheter dependence is reasonable. Steal, in particular, makes decision making quite complex, as loss of hand function becomes an issue alongside that of access. Finally, patient factors, both organic (psychiatric issues, dementia, or extreme living conditions) and psychological (the stress induced by personal or witnessed problems) are very common. A bad experience that is brushed aside or dealt with purely mechanistically may amplify the reaction with negative views of definitive access and a preference for permanent catheter use. The experiences of the patient on dialysis are unique to them and the concept of best access requires individualisation considering the overall situation rather than just the access issues. Very few patients who require haemodialysis will start their journey with a single distal fistula which is functional and remains free of complications, and it is critical that this concept be discussed at the onset of the journey.