Approach to Permanent Hemodialysis Access in Obese Patients

Obesity has reached an epidemic in the United States and, not surprisingly, there has been a dramatic increase in obesity-associated comorbidities, complete with a host of new, related surgical challenges. The creation and maintenance of permanent hemodialysis access, particularly autogenous access, is generally considered more difficult in the obese patient because of the increased risk of perioperative complications, as well as a decreased maturation rate. Most of the data documenting these adverse outcomes come from retrospective studies and, therefore, the reliability of the data is somewhat limited, given the inherent selection bias. In the United States, most obese patients dialyze through prosthetic access, despite the national initiatives targeted at maximizing autogenous access. However, it is possible to construct an autogenous access in most patients, including obese patients, presenting for permanent access using proper, diligent preoperative imaging and an aggressive postoperative surveillance protocol until access maturation. This is facilitated by careful preoperative planning and liberal use of multiple diagnostic and therapeutic maneuvers to improve overall access function. In this review, the outcomes associated with permanent hemodialysis access in the obese are discussed and helpful suggestions to facilitate a functional access provided.