Despite the importance of hemodialysis vascular access, the cost of vascular access care has not been studied in detail. A prospective cost analysis was performed among incident hemodialysis patients to determine the cost of vascular access care overall and on the basis of access type. Detailed clinical and demographic information, as well as data on access type, was collected for all local incident hemodialysis patients between July 1, 1999, and November 1, 2001. A comprehensive measure of total vascular access costs, including surgery, radiology, hospitalization for access complications, physician costs, costs for management of outpatient bacteremia, and vascular access monitoring costs, was obtained. Costs are reported in 2002 Canadian dollars (1CAN$ = 0.69US$). A total of 239 consecutive incident hemodialysis patients were identified, 49, 157, and 33 of whom were dialyzed exclusively with a catheter or had a native arteriovenous fistula or synthetic graft attempted, respectively. In year 1, 18.4% of all hospital admissions were for vascular access-related complications. The mean cost of all vascular access care in year 1 was CAN$6890 (median $4020; interquartile range [IQR] $2440 to $7540). The mean cost of access care per patient-year at risk for maintaining a catheter exclusively, attempting an arteriovenous fistula, or attempting a graft was $9180 (median $3812; IQR $2250 to $7762), $7989 (median $4641; IQR $3035 to $8832), and $11,685 (median $8152; IQR $3395 to $12,908), respectively (P= 0.01). Vascular access care is responsible for a significant proportion of health care costs in the first year of hemodialysis. These results support clinical practice guidelines that recommend preferential placement of a native fistula.