title: Who should be referred for a fistula? A survey of nephrologists.
abstract: BACKGROUND
  There is marked variation in the use of the arteriovenous fistula (AVF) across programmes, regions and countries not explained by differences in patient demographics or comorbidities. The lack of clear criteria of who should or should not get a fistula may contribute to this, as well as barriers to creating AVFs.
  
  
  METHODS
  We conducted a survey of Canadian and American nephrologists to assess the patient variables considered to determine the timing and type of access requested. Perceived barriers and absolute contraindications to access were also collected.
  
  
  RESULTS
  An immediate referral for a fistula was more highly preferred when patients are <65 years old, have minimal comorbidities or have no history of failed accesses. In older patients, and in those with increased comorbidities or a previously failed fistula, US nephrologists selected arteriovenous grafts as an alternative to the fistula, while Canadian nephrologists selected primarily catheters. Referral for vascular mapping was more common in the USA than in Canada. Gender did not influence the timing or the type of access. Perceived barriers to establishing a mature fistula included patient refusal for creation (77%) or cannulation (58%), delay in decision regarding dialysis modality (71%), wait time for surgical creation (55%) and high failure-to-mature rate (52%). We found that 27% of Canadian and 43% of American nephrologists indicated no absolute contraindications for permanent vascular access.
  
  
  CONCLUSIONS
  This study demonstrated marked variability in timing and criteria used to select patients for referral for a vascular access between nephrologists practicing within Canada and the USA. Establishing minimal eligibility criteria for fistulae is an important area of future research.
authors.affiliation: Division of Nephrology, London Health Sciences Center and the University of Western Ontario, London, ON, Canada.
authors.forename: Wang
authors.initials: W
authors.lastname: Xi
authors.forename: Jennifer
authors.initials: J
authors.lastname: MacNab
authors.forename: Charmaine E
authors.initials: CE
authors.lastname: Lok
authors.forename: Timmy C
authors.initials: TC
authors.lastname: Lee
authors.forename: Ivan D
authors.initials: ID
authors.lastname: Maya
authors.forename: Michele H
authors.initials: MH
authors.lastname: Mokrzycki
authors.forename: Louise M
authors.initials: LM
authors.lastname: Moist
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data*; D002170:Canada; D000075202:Contraindications; D003625:Data Collection; D003657:Decision Making; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010820:Physicians; D012042:Registries; D006435:Renal Dialysis / Q000379:methods*; D013997:Time Factors; D014481:United States