Pursuing permanent hemodialysis vascular access in patients with a poor prognosis: juxtaposing potential benefit and harm

Am J Kidney Dis. 2012 Dec;60(6):1023-31. doi: 10.1053/j.ajkd.2012.07.020. Epub 2012 Sep 19.


For patients with end-stage renal disease requiring hemodialysis, the native arteriovenous fistula remains the gold standard of vascular access, with tunneled cuffed central venous catheters reserved for temporary use or as a last resort in patients for whom a permanent vascular access is not possible. It is expected that most patients receiving hemodialysis will be suitable for arteriovenous fistula placement, with suitable patients defined as those: (1) for whom long-term dialysis is expected to confer benefit, (2) with vascular anatomy amenable to arteriovenous fistula placement, and (3) with progressive irreversible kidney failure who are more likely to require dialysis than to die before reaching dialysis dependence. The present article reviews considerations for vascular access decision making, focusing on older patients and those with a poor prognosis, weighing the risks and benefits of arteriovenous fistulas, arteriovenous grafts, and central venous catheters and emphasizing that in the process of vascular access decision making for such patients, medical and ethical obligations to avoid central venous catheters must be balanced by the obligation to do no harm.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Aged
  • Arteriovenous Shunt, Surgical / adverse effects
  • Arteriovenous Shunt, Surgical / methods*
  • Catheterization, Central Venous / adverse effects
  • Catheterization, Central Venous / methods*
  • Female
  • Humans
  • Kidney Failure, Chronic / diagnosis*
  • Kidney Failure, Chronic / etiology
  • Kidney Failure, Chronic / therapy*
  • Prognosis
  • Renal Dialysis / methods*