• Jordan R Casey, Camilla S Hanson, Wolfgang C Winkelmayer, Jonathan C Craig, Suetonia Palmer, Giovanni F M Strippoli, and Allison Tong.
• Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, NSW, Australia.
• Am. J. Kidney Dis. 2014 Dec 1; 64 (6): 937-53.

BackgroundDelayed creation of vascular access may be due in part to patient refusal and is associated with adverse outcomes. Concerns about vascular access are prevailing treatment-related stressors for patients on hemodialysis therapy. This study aims to describe patients' perspectives on vascular access initiation and maintenance in hemodialysis.Study DesignSystematic review and thematic synthesis of qualitative studies.Setting & PopulationPatients with chronic kidney disease who express opinions about vascular access for hemodialysis.Search Strategy & SourcesMEDLINE, EMBASE, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched to October 2013.Analytical ApproachThematic synthesis was used to analyze the findings.ResultsFrom 46 studies involving 1,034 patients, we identified 6 themes: heightened vulnerability (bodily intrusion, fear of cannulation, threat of complications and failure, unpreparedness, dependence on a lifeline, and wary of unfamiliar providers), disfigurement (preserving normal appearance, visual reminder of disease, and avoiding stigma), mechanization of the body (bonded to a machine, internal abnormality, and constant maintenance), impinging on way of life (physical incapacitation, instigating family tension, wasting time, and added expense), self-preservation and ownership (task-focused control, advocating for protection, and acceptance), and confronting decisions and consequences (imminence of dialysis therapy and existential thoughts).LimitationsNon-English articles were excluded.ConclusionsVascular access is more than a surgical intervention. Initiation of vascular access signifies kidney failure and imminent dialysis, which is emotionally confronting. Patients strive to preserve their vascular access for survival, but at the same time describe it as an agonizing reminder of their body's failings and "abnormality" of being amalgamated with a machine disrupting their identity and lifestyle. Timely education and counseling about vascular access and building patients' trust in health care providers may improve the quality of dialysis and lead to better outcomes for patients with chronic kidney disease requiring hemodialysis.Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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