A subset of patients requiring hemodialysis access will be actively using or former users of substances of abuse. Substances of abuse can be wide ranging from marijuana to heroin, cocaine, and methamphetamines. Multiple routes of administration, including the intravenous route, are used. A recent report from the Centre for Disease and Control (CDC) suggests that despite successes in the “war on drugs,” heroin abuse in the USA is still a widespread problem [2]. There are several reasons why creating hemodialysis access in these patients is challenging.

Patients addicted to IVDU have often “burned” their superficial venous system from heroin, cocaine, or other injected substances due to the toxic impurities that are injected. As a result, not only are superficial veins as options for autogenous hemodialysis access limited, simple intravenous access is often a major problem, and these patients usually require central line placement for venous access when presenting for medical care. Hence, the possibility of central venous stenosis should be entertained in all of these patients during evaluation for hemodialysis access. Lastly, a high percentage of these individuals will have had previous incision and drainage (I and D) procedures for abscesses associated with subcutaneous drug injection. The upper extremities in these patients often have numerous scars, posing additional challenges in accessing arteries and superficial or deep veins for the creation of arteriovenous fistulas (AVF) or in tunneling arteriovenous grafts (AVG).