General Decision Making for Hemodialysis Access Planning

Once the patient has been thoroughly evaluated—by means of relevant medical history and physical examination, and full ultrasound mapping of both arms—it is time to make decisions about their access plan. The patient is, of course, the final decision-maker in the process, but it is the physician’s obvious role to make recommendations as to the best access option, and discuss risks, benefits, and alternatives (including “Plan B,” “Plan C,” and so on). KDOQI recommends making this decision in the context of a “Life Plan.” While helpful in theory, unless the patient is cared for in a dedicated center, the physician does not always have the luxury of controlling much beyond this isolated access encounter, and hence must include the psychosocial circumstances influencing access in his or her decision-making. The first step should be to pick a side, and this will depend somewhat upon whether the provider follows a “fistula first” versus “catheter last” philosophy. Following this, the exact plan will depend upon the principles of inflow, outflow, and conduit. This process is, surprisingly, not amenable to a single flowchart, and incorporates the provider’s experience and outcomes to a substantial degree.