New frontiers in vascular access practice: from standardized to patient-tailored care and shared decision making
Vascular access planning is critical in the management of patients with advanced kidney disease who elect hemodialysis for kidney replacement therapy. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal-i.e, arteriovenous fistula-and least preferred-i.e., central venous catheter-type of access. This homogenized approach to vascular access care emerged ineffective in the ever increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge limitations of standardized care and encourage tailoring vascular access care based on patient and disease characteristics. In this article we discuss available literature in support of patient-tailored access care based on differences in vascular access outcomes by biologic and social factors-age, sex and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice co-factors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual based on biological factors, fluctuating clinical needs, values and preferences.