Background: Currently, more than 600,000 Americans suffer from End Stage Renal Disease (ESRD) and Epidemiological projections indicate that the population of patients with the disease may exceed 2 million by 2030. ESRD imposes significant social and economic burdens on the US economy with estimated annual treatment costs in excess of $30 billion. Vascular Access (VA) is a life-saving procedure for ESRD patients. However, a great proportion of the costs and social suffering among patients have been attributed to poor selection and management of VA devices for hemodialysis. A properly functioning vascular access is therefore critical for performing efficient and effective hemodialysis (HD) therapy. In promoting their Kidney Disease Outcomes Quality Initiative (KDOQI), the National Kidney foundation (NKF) included guidelines for hemodialysis vascular access. Despite this, cost and clinical outcomes associated with VA continue to be sub-optimal. It has been shown that good quality guidelines can optimize patient outcomes and healthcare resource use. Purpose: This study critically appraised the quality of the National Kidney Foundation's (KDOQI) with emphasis on the recommendations for hemodialysis vascular access. The study also made recommendations for improving critical aspects of the guideline where necessary. Methods: Four independent clinicians appraised the quality of the guideline using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. The AGREE II consists of 23 key items categorized into 6 quality domains: scope and purpose (3 items), stakeholder involvement (3 items), rigor of development (8 items), clarity of presentation (3 items), applicability (4 items), and editorial independence (2 items). The appraisers were asked to provide comments where necessary, to justify their ratings. They were also asked to provide an overall assessment of the guideline and whether or not they would recommend it for practice based on the number of domains that received standardized scores > 60 % (recommended), 30-60 % (recommended with provisions or exceptions) and < 30 (not recommended). To increase the reliability of the appraisal, only relevant clinicians (Vascular Surgeons, Nephrologists, and Registered Nurses) were recruited for participating in the study. Domain quality scores were obtained using a standardized equation from the AGREE II. A 2-way ANOVA random effects model was fitted to the data for computing the Inter Rater Agreement using SPSS. Results: The quality scores for each of the 6 domains were as follows: Editorial Independence (97.92%) Stakeholder Involvement (97.22%), Rigor of development (95.83%), Clarity of Presentation (90.72%), Applicability (87.55%) and Scope and Purpose (83.33%). The overall agreement on guideline quality as determined by the intra-class correlation coefficient (ICC) was 0.07 (-0.37, 0.477) indicating considerable disagreement among the appraisers. Conclusion: All six domains received high quality scores (> 60%) according to the AGREE II criteria. However, the high level of disagreement among appraisers indicates that the overall quality of the guideline is questionable. This is particularly evident since only 2 of the 4 clinicians recommended it for practice without alterations or modifications. The study findings are consistent with industry trends but have also brought to light several areas for improvement in the NKF-KDOQI recommendations for vascular access. These include interventions for a wider range of hemodialysis patients, patient-specific recommendations with respect to competing VA interventions and patient demographics and the removal of barriers that limit the implementation of the guideline. Despite this, the NKF-KDOQI recommendations for vascular access can still help clinicians make adequate treatment decisions for improving cost and clinical outcomes associated with vascular access management.