When Should You Start Planning a Dialysis Fistula?
ENGLISH
“My kidney function may continue to decline. Does that mean I need a fistula now?” Planning a dialysis access does not mean that dialysis must start immediately, and not every person with advanced chronic kidney disease needs a fistula.
The purpose is to allow enough time to assess the arm vessels, choose an appropriate access and reduce the chance of needing an urgent central venous catheter if haemodialysis becomes necessary.
An arteriovenous fistula (AV fistula) is created by connecting an artery to a superficial vein. The increased blood flow allows the vein to enlarge and strengthen so it can later support repeated haemodialysis cannulation.
eGFR stands for estimated glomerular filtration rate. It is calculated from a blood creatinine result together with factors such as age and sex, and estimates how well the kidneys filter blood and remove waste. Think of it as a kidney filtration indicator: in general, a lower number means poorer filtering function. eGFR is not a percentage, and a single result does not decide whether dialysis is needed.
- eGFR (an estimate of kidney filtering function) below approximately 15–20 mL/min/1.73m² with progressive decline
- An estimated 2-year risk of kidney replacement therapy above 40%
- Haemodialysis is likely to become the preferred future option
- Vascular anatomy may be difficult and needs earlier preservation and assessment
1.Who should start discussing dialysis access planning?
- The KDIGO 2024 CKD guideline advises considering planning for kidney transplantation and/or dialysis access in adults when eGFR is below approximately 15–20 mL/min/1.73m², or when the estimated 2-year risk of kidney replacement therapy is above 40%.
- The decision also considers the trend across repeated tests, proteinuria, recurrent acute kidney injury, and whether fluid status, potassium, acid–base balance, blood pressure or nutrition are becoming difficult to control. A single eGFR result is not enough.
- If the nephrology team believes haemodialysis is likely to become the preferred future option, it is reasonable to learn about fistulas, grafts and catheters and arrange vascular assessment.
2.Who may need earlier vessel assessment?
- People with diabetes, peripheral arterial disease, small arm vessels or a previous failed access.
- People with previous central venous catheters, PICCs or pacemaker leads, because these may affect central veins and future access options.
- When instructed by the care team, avoid unnecessary blood draws, intravenous lines or PICCs in the arm being preserved. Ask nephrology which arm should be protected rather than choosing a side yourself.
3.Why not wait until dialysis is urgent?
- An AV fistula needs time to mature, and some fistulas require further assessment, angioplasty or surgical revision before use.
- Earlier planning allows physical examination and ultrasound mapping of artery and vein size, course, depth and blood flow, followed by access creation at a time matched to the expected course of kidney disease.
- However, earlier is not always better. A fistula may be unnecessary when kidney function is stable, pre-emptive transplantation or peritoneal dialysis is preferred, or the expected benefit of haemodialysis is limited by overall health and personal goals.
4.Fistula, graft or catheter—which access is suitable?
- A native AV fistula may suit someone with appropriate arteries and veins and enough time for maturation, but not every fistula matures successfully.
- An AV graft may be considered when native veins are unsuitable or access may be needed sooner. Ongoing assessment for stenosis and infection is still required.
- A central venous catheter is commonly used when dialysis is urgent or no other access is immediately available and is usually considered temporary.
- The KDOQI guideline emphasizes an individualized ESKD Life-Plan. Dialysis modality, transplantation, anatomy, urgency, comorbidities and personal preferences should be considered together. An AV fistula is an important option for a suitable patient, but it is not the only correct option for everyone.
5.What happens during the first vascular access assessment?
- We review hand dominance, previous catheters, pacemaker leads, surgery and the kidney replacement plan discussed with nephrology.
- Pulses, skin, veins and circulation are examined in both arms, followed by ultrasound mapping of the arteries and veins.
- Vascular surgery and nephrology then coordinate whether an access is needed and select its type, location and timing. Access planning and starting dialysis are separate decisions.
💡 What can you do at each stage?
| Current situation | Useful next step | What it does not mean |
|---|---|---|
| eGFR around 15–20 or rising 2-year kidney-failure risk | Discuss dialysis, transplantation and conservative care with nephrology | Dialysis does not start automatically |
| Haemodialysis is likely to be a future choice | Arrange vascular-surgery review and arm-vein ultrasound | Not everyone automatically needs a native fistula |
| Small vessels or previous catheter, PICC or pacemaker | Share this history early and assess available veins and central venous outflow | Do not choose the preservation arm yourself |
| Uncontrolled fluid overload, hyperkalaemia, acidosis or uraemic symptoms | Seek prompt nephrology assessment for kidney replacement therapy | eGFR alone does not decide dialysis timing |
Frequently asked questions
Does every person with stage 4 CKD need a fistula?
No. Progression rate, 2-year kidney-failure risk, expected dialysis modality, vascular anatomy, overall health and personal goals all matter.
Does fistula creation mean dialysis will start soon?
No. Access creation prepares for possible haemodialysis. Dialysis initiation is based on symptoms, quality of life, kidney function, laboratory findings and patient preferences.
Will surgery be booked at the first visit?
Not necessarily. The first assessment usually reviews the nephrology plan and previous procedures, then examines and maps the arm vessels before timing is discussed.
Note: Planning an access does not mean starting dialysis immediately. Whether an access is needed, which type is suitable and when to create it should be decided together by the patient, nephrology and vascular surgery teams.
Related vascular guides
References
- Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International. 2024;105(Suppl 4S):S117–S314. View source
- Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. American Journal of Kidney Diseases. 2020;75(4 Suppl 2):S1–S164. View source
This article provides general health education and does not replace individual medical assessment. Kidney-function trajectory, dialysis modality, access type and timing require personalised review.
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