Taking care of dialysis access remains part and parcel of day-to-day nephrology practice. As the ‘lifeline’ of the dialysis patient, it poses multiple challenges related not only to its creation and maintenance, but also to its impacts on safety and the expenses associated with managing access complications. Increasing involvement of nephrologists in access care, including diagnostic ultrasound and interventional procedures, demands better education of general nephrologists to be able to interact intelligently and collaboratively with their interventional colleagues. Transformative technology now provides better tools and will soon allow percutaneous creation of vascular access by nephrologists. These advances and an emphasis on placing peritoneal dialysis access will facilitate attainment of the goals of the ‘Fistula First, Catheter Last’ paradigm to improve patient outcomes.