Increasing AV fistulas: revisiting a time-tested solution

Despite having the lowest complication rate of all hemodialysis accesses, the prevalence of autologous arteriovenous (AV) fistulas has declined to 28% in the United States. The reasons for this decline include high early AV fistula failure rates, long maturation times, the frequent need for emergent dialysis, unavailable or poor pre-ESRD programs and planning, patient resistance to the realities of impending ESRD, and financial disincentives to AV fistula placement. Despite these barriers, programs throughout the country have demonstrated the ability to increase AV fistula prevalence to more than 50%. The strategies employed have included increased reliance on upper arm brachiocephalic and transposed basilic vein fistulas, the use of preoperative imaging to identify the best sites for fistula creation, and aggressive attempts at salvage of nonmaturing fistulas. Other groups have systematically and successfully replaced failed grafts with upper arm brachiocephalic or bracheobasilic fistulas. These experiences clearly show that exceeding the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) goal of more than 50% fistula placement is achievable in the United States. Declining numbers of AV fistulas are the result of a combination of factors, including changes in our patient population and learned practice patterns coupled with a failure of our delivery system to provide education, timely referral, and incentives for fistula placement. Increasing AV fistula prevalence in the United States is achievable and will improve patient outcomes and decrease the costs of ESRD.