The Current State of Hemodialysis Access and Dialysis Access Initiatives in the United States

Abstract

Although the past five decades have witnessed dramatic transformations in dialysis technologies and health-care infrastructure, the fundamental dependence of each patient undergoing maintenance hemodialysis on long-term reliable vascular access has remained unchanged. The past decade in the United States has witnessed the development and implementation of a number of vascular access initiatives led by a variety of different stakeholders focused on increasing the prevalence of arteriovenous fistulas and limiting the use of central venous catheters in hemodialysis patients. These have included the Fistula First Initiative most prominently and also include the Centers for Medicare and Medicaid Services End-Stage Renal Disease Quality Incentive Program, the Healthy People 2020 campaign, and the Renal Physicians Association Vascular Access Initiative. Coinciding with implementation of these initiatives has been an acceleration of a marked transition from the dominant use of arteriovenous grafts to that of arteriovenous fistulas among individuals in the United States undergoing maintenance hemodialysis. In contrast to the distribution of vascular access types used by prevalent patients, the distribution of access use by patients starting maintenance hemodialysis has shown remarkably little change over the past decade. Over the past 3–4 years, recognition of the plateauing proportion of prevalent hemodialysis patients using fistulas as well as the persistently and unacceptably high proportion of patients starting dialysis with catheters has led to calls to reorient the Fistula First Initiative to include a renewed emphasis on primarily discouraging the long-term use of central venous catheters.