The rate of end-stage kidney disease (ESKD) has been steadily increasing in the population, with an overall increase in prevalence of 37.8% from 2001-2019 with more than 800,000 patients living with ESKD in 2020 [1,2]. The World Health Organization defined older adults as individuals 65 years or older [3], and there is evidence that this population is the fastest growing segment of the ESKD population in need of hemodialysis (HD) [4]. This demographic shift presents unique challenges in vascular access planning and management, and requires a careful balance between best-practice guidelines and individualized age-specific considerations.

The most widely used, and generally preferred, renal replacement therapy is HD through an arteriovenous fistula (AVF), due to increased durability and decreased complication risk compared with arteriovenous grafts (AVGs) or venous catheters [5]. Due to this increased durability, vascular quality initiatives, such as the Fistula First Breakthrough Initiative, arose as guidelines to increase AVF placement in all eligible patients to mitigate postoperative complications [6]. However, age-related changes to vessel biology, increased prevalence of cardiovascular comorbidities, and limited life expectancy necessitate careful consideration surrounding the timing and type of access creation [7,8]. The traditional notion of fistula first may require re-evaluation in this population when considering the maturation time, likelihood of successful fistula use, and patient-specific goals. Therefore, we sought to comprehensively describe the unique challenges affecting surgical planning and considerations of anatomy, autonomy, and frailty during vascular access planning in older patients to define a class of high-risk older patients and aid in life-plan management strategies. Special consideration will be given to the necessity of a multidisciplinary team in determining the appropriate treatment plan.