More than 800,000 people in the United States have end-stage kidney disease (ESKD) [1]. Although renal transplantation is considered the optimal treatment for ESKD, hemodialysis (HD) remains one of the most common forms of therapies. HD access, the means by which patients are able to undergo HD, is a vital component of patient preparation for, and administration of, this therapy and, in fact, may impact the outcome of patients with ESKD. Unfortunately, the HD access itself is associated with a wide range of complications, such as infection, bleeding, thrombosis, and HD access–related steal syndrome. These complications often require surgical interventions and hospitalizations [2]. All of these factors have a significant impact on a patient's quality of life, morbidity, and mortality. Of the HD access modalities, arteriovenous fistula (AVF) is often the preferred method for long-term access because of the lower risk of infectious complications and better long-term patency rates compared with tunneled central venous catheters (CVCs) and arteriovenous grafts (AVGs) [2,3].

There is wide variability in patient access to HD, HD access options, and related outcomes [4]. Disparities are especially prevalent in vulnerable populations, such as racial and ethnic minoritized groups, females, and older adults. Currently, females patients represent 37% of new patients requiring HD [1]. However, females are less likely to have HD initiated via AVF compared with men [5] and have higher rates of AVG and CVC placement [6]. Studies also suggest that females have lower rates of AVF patency and take a longer time to achieve fistula maturation [7,8].

Identifying and understanding the causes of disparities and related poor outcomes is crucial to improving care for patients with renal failure and vulnerable populations. There is a paucity of literature investigating the etiologies of these disparities and even less so describing methods of outcome improvement. It was, therefore, the goal of this systematic review to collate and summarize the current literature on HD access outcomes in females, identifying differences between females and men, and to provide a foundation for future research.