For an adult with end‑stage renal disease requiring chronic hemodialysis, what is the recommended first‑line vascular access and its management?

Hemodialysis Vascular Access: First-Line Recommendation

The arteriovenous fistula (AVF) is the recommended first-line vascular access for adults with end-stage renal disease requiring chronic hemodialysis, with a specific preference hierarchy starting with radial-cephalic (wrist) fistula, followed by brachial-cephalic (elbow) fistula, then arteriovenous graft, and finally tunneled central venous catheter only as a last resort. 1, 2

Why AVF is Superior: Evidence-Based Rationale

Infection Risk Profile

• AVFs have the lowest infection rate of all vascular access types at only 1-4% over their entire use-life 2
• The relative risk of bacteremia with AVFs is 7 times lower than with catheters 2
• Arteriovenous grafts have substantially higher infection rates at 11-20% during their expected usage period 2
• Tunneled catheters carry a 50% removal rate due to infection at 1 year of use 2

Patency and Longevity

• AVFs demonstrate the best 4-5 year patency rates compared to all other access types 1
• The target thrombosis rate for AVF should be less than 0.25 episodes per patient-year at risk (after excluding initial failures within first 2 months) 1, 2
• AVFs require 3-7 times fewer complication events than prosthetic grafts 2

Impact on Mortality and Morbidity

• AVFs are associated with lower mortality and hospitalization rates compared to other access types 2
• Vascular access-related infections are a primary cause of morbidity and mortality in dialysis patients, making AVF selection critical 2

Specific AVF Placement Hierarchy

First Choice: Radial-Cephalic (Wrist) AVF

• This distal location should be attempted first to preserve more proximal sites for future access if needed 1
• Requires radial artery diameter typically >1.9 mm and cephalic vein diameter >1.7 mm for optimal outcomes 3

Second Choice: Brachial-Cephalic (Elbow) AVF

• Used when distal vessels are inadequate 1
• Provides excellent long-term patency with 4-year primary functional patency rates of 68.9% 4
• Offers early maturation and high primary patency rates 5

Third Choice: Brachial-Basilic AVF with Transposition

• Reserved for patients whose distal vascular bed is depleted 5
• Demonstrates 2-year primary patency rates of 80% 5

Critical Timing Considerations

Early Referral is Essential

• AVF creation should occur 3-4 months before anticipated hemodialysis initiation to allow adequate maturation 1
• Early referral to nephrology enables proper access planning and dramatically reduces emergency catheter placement 1, 2
• Late referral results in up to 73% of patients being hospitalized for temporary dialysis catheter access 1

Bridging Strategy

• If hemodialysis must begin before AVF maturation, use a cuffed catheter as a temporary bridge rather than defaulting to an arteriovenous graft 1
• This preserves the long-term benefits of AVF while avoiding premature graft placement 1

When NOT to Use AVF as First-Line

Acceptable Catheter Use (Temporary Only)

• Less than 10% of chronic maintenance hemodialysis patients should be maintained on catheters as permanent access 1
• Chronic catheter use is defined as catheter use exceeding 3 months without a maturing permanent access 1

Arteriovenous Graft Consideration

• May be considered in older adults (≥60 years) with cardiovascular disease, peripheral arterial disease, or diabetes where AVF maturation is uncertain 6
• However, this remains controversial and AVF should still be attempted first in most cases 1, 2

Access Management and Surveillance

Quality Assurance Targets

• Centers should maintain graft thrombosis rates not exceeding 0.5 thrombotic episodes per patient-year at risk 1
• AVF thrombosis rates should remain below 0.25 episodes per patient-year at risk 1, 2

Monitoring Protocol

• Establish a database to track access types created and complication rates 1
• Implement multifaceted quality assurance programs to detect at-risk accesses before thrombosis occurs 1
• Physical examination should assess for adequate thrill, signs of stenosis, or steal syndrome 1

Common Pitfalls to Avoid

The "Fistula First" Trap

• While AVF is preferred, the 2019 KDOQI guidelines shifted from rigid "Fistula First" to individualized "Patient Life-Plan" approach 1
• This means considering patient longevity, comorbidities, and functional status—not blindly placing AVF in all patients 1

Inadequate Maturation Time

• Rushing to use an immature AVF leads to failure 1
• Plan ahead: if dialysis is needed urgently, use a temporary catheter rather than compromising AVF maturation 1

Ignoring Vascular Anatomy

• Pre-operative vascular mapping is essential 3
• Radial artery diameter at the wrist is a significant predictor of immediate AVF function 3
• Attempting AVF with inadequate vessel size leads to primary failure 3

Central Venous Catheter Overuse

• Chronic catheter use is associated with lower blood flow rates, compromising dialysis adequacy 1
• Catheters carry risk of central venous stenosis, which can preclude future permanent access creation 1
• Patient education is critical: the ease and painlessness of catheters may foster reluctance to accept AVF despite superior outcomes 1