Referral for vascular access where appropriate

Why timing matters

Timely referral for dialysis vascular access (arteriovenous fistula, AV graft, or tunnelled central venous catheter) is central to reducing dialysis-related morbidity - an AVF created too late forces reliance on a catheter, with substantially higher infection and mortality risk
AV fistula is the preferred access (lowest infection/thrombosis rate, best longevity) but takes 6-8 weeks minimum to mature before use, sometimes longer - the core reason early referral matters

Access type	Time to maturation	Relative risk
AV fistula	6-8+ weeks	Lowest infection/complication rate - preferred
AV graft	2-4 weeks	Higher infection/thrombosis risk than a fistula
Tunnelled central venous catheter	Immediate use	Highest infection risk - used when fistula/graft is not feasible or not yet ready

KDOQI: refer for vascular access assessment/creation when eGFR reaches 15-20 mL/min/1.73m2 with progressive decline, and educate on all RRT modalities (including transplant) from eGFR <=30 (CKD stage G4)
Vein mapping (ultrasound) prior to surgery assesses suitability for fistula vs graft

Multidisciplinary planning - nephrology, vascular surgery, and (where relevant) pre-emptive transplant assessment run in parallel, not sequentially, once CKD is progressive
Protect potential access sites early (avoid cannulation/PICC lines in the non-dominant forearm in patients with progressive CKD)

CKD progression, pre-emptive kidney transplantation, catheter-related bloodstream infection

Late referral (dialysis starting via catheter without a mature permanent access) is associated with higher infection rates, hospitalisation, and mortality compared with starting via a mature fistula

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