title: Patients' perspectives on hemodialysis vascular access: a systematic review of qualitative studies.
abstract: BACKGROUND
  Delayed 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.
  
  
  METHODS
  Systematic review and thematic synthesis of qualitative studies.
  
  
  METHODS
  Patients with chronic kidney disease who express opinions about vascular access for hemodialysis.
  
  
  METHODS
  MEDLINE, EMBASE, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched to October 2013.
  
  
  METHODS
  Thematic synthesis was used to analyze the findings.
  
  
  RESULTS
  From 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).
  
  
  CONCLUSIONS
  Non-English articles were excluded.
  
  
  CONCLUSIONS
  Vascular 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.
authors.affiliation: 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.
authors.forename: Jordan R
authors.initials: JR
authors.lastname: Casey
authors.affiliation: 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.
authors.forename: Camilla S
authors.initials: CS
authors.lastname: Hanson
authors.affiliation: Division of Nephrology, Stanford University, Palo Alto, CA.
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
authors.affiliation: 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.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Craig
authors.affiliation: University of Otago Christchurch, Christchurch, New Zealand.
authors.forename: Suetonia
authors.initials: S
authors.lastname: Palmer
authors.affiliation: Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Medical Scientific Office, Diaverum, Lund, Sweden; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
authors.forename: Giovanni F M
authors.initials: GF
authors.lastname: Strippoli
authors.affiliation: 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. Electronic address: allison.tong@sydney.edu.au.
authors.forename: Allison
authors.initials: A
authors.lastname: Tong
mesh_terms: D002404:Catheterization / Q000379:methods* / Q000523:psychology; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D057240:Patient Preference / Q000523:psychology; D006435:Renal Dialysis / Q000295:instrumentation* / Q000523:psychology; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D062666:Vascular Access Devices
keywords: Fistula First; Patient perspectives; chronic kidney disease; hemodialysis; illness experiences; patient-centered care; predialysis care; qualitative research; renal replacement therapy (RRT); thematic synthesis; vascular access