When Is the Right Time for Arteriovenous Fistula Placement in Patients with End-Stage Renal Disease?

dialysis), just prior (1–4 months) and late creations (within 1 month of dialysis start) . They found that AVF creation at least 4 months before starting dialysis was associated with the lowest risk of sepsis and death. The elderly, diabetics and women provide unique subsets of patients with increased risk when starting dialysis. In individuals with advanced CKD, particularly the elderly, women or those with multiple comorbid conditions, serum creatinine-based estimated glomerular filtration rate (eGFR) may be misleading due to the dependence of serum creatinine on creatinine generation from muscle mass. The rate of renal function decline may be slower with increased age and this may be due to decreased muscle mass in the elderly. The initiation of dialysis and urea clearance needs to be defined separately for this population of patients. This fact may contribute to the overall patency rate of primary AVF, which is lower in these high-risk groups. ESRD patients with advanced age and AVF access may die before the need to use the access. In individual cases, the need to start dialysis may be delayed due to patient preference. Close diet guidelines can prolong the start of hemodialysis, allowing for successful placement of AVF or an arteriovenous graft (AVG). We need to consider the overall comorbid conditions, life expectancy, age and patient preference when referring for permanent hemodialysis access. Vascular access for hemodialysis patients has a significant impact on the morbidity and mortality of patients with end-stage renal disease (ESRD). Although significant improvements in the number of patients with arteriovenous fistula (AVF) access in the United States have been made, 80% of patients in the United States that start hemodialysis have a catheter access [1] . While cardiovascular disease is the leading cause of death in patients with ESRD, the second most common cause is infection. Mortality is common in the first year after initiation of hemodialysis from bacteremia and sepsis from catheter access [1, 2] . Delay in AVF placement leads to increased reliability on catheter access which contributes significantly to morbidity, mortality and cost of providing hemodialysis. The timing of AVF placement and avoidance of catheter access is critical to the successful transition from chronic kidney disease (CKD) to ESRD with hemodialysis. A staging system for CKD has been developed, which has identified specific interventions to enhance the health and outcomes of patients with ESRD. While these stages have been an effective means of communication among disciplines, they have not been able to determine the optimal time for AVF access. More simply put, CKD staging does not predict the time to start dialysis. There have been other attempts to define the best time for access placement. Oliver et al. [2] followed a large cohort of patients with early creation (at least 4 months prior to needing Published online: March 17, 2017 Nephrology American Journal of