How to increase the use of native arteriovenous fistulae for haemodialysis.

The arteriovenous fistula (AV fistula) is the preferred vascular access for haemodialysis. Recent clinical practice guidelines recommend the creation of vascular access (native fistula or synthetic graft) before the start of chronic haemodialysis therapy to prevent the need for complication-prone dialysis catheters. Late referral to a nephrologist is an important factor contributing to the high rate of dialysis-catheter use and the low rate of AV fistula use. Efforts to improve the vascular access experience of patients in the initial stages of haemodialysis therapy need to focus on all persons involved in predialysis care, including patients, referring physicians, surgeons, and nephrologists. An aggressive policy of venous preservation early before the beginning of any renal replacement therapy is needed. The placement and adequate maturation of AV fistula before the initiation of haemodialysis therapy requires timely patient education and counselling, selection of the preferred renal replacement modality, selection of an access type and location, and creation of the access at least several weeks to months in advance of its expected date. However, AV fistula failure has become more common over the last three decades as more patients are older, and have diabetes or vascular disease. AV fistulae failures have been attributed to inadequate vessels used for surgery. Preoperative vascular mapping has been shown to result in an increased placement of AV fistulae. In general, physical examination and ultrasound assessment are available and obligatory for vascular evaluation. The ultimate goal of preoperative assessment is to completely prevent non-maturation by optimal selection of the site of anastomosis and by identification and treatment of pre-existing lesions before vascular access creation.