Selection of type of access Date written: March 2012 Author: Pamela Lopez-Vargas, Kevan Polkinghorne

GUIDELINES No recommendations possible based on Level I or II evidence

SUGGESTIONS FOR CLINICAL CARE (Suggestions are based on Level III and IV evidence) Whenever possible it is suggested that a native arteriovenous fistula is created and used for haemodialysis, as it is superior to an arteriovenous graft and to a central venous catheter. (Level III evidence) When a native arteriovenous fistula is not possible, an artificial arteriovenous graft should be used in preference to a central venous catheter. Arteriovenous grafts have similar patency to arteriovenous fistula after accounting for arteriovenous fistula primary failure at the expense of greater interventions to maintain patency. (Level III evidence)

IMPLEMENTATION AND AUDIT An implementation study was conducted by CARI in 2007-2009 to identify the barriers and facilitators for vascular access creation, as well as identifying implementation strategies for improving vascular access creation in patients commencing chronic haemodialysis. Strategies to facilitate timely access creation included the implementation of a pre-dialysis clinical care pathway as well as frequent audit and feedback of unit results.

BACKGROUND Patients with chronic kidney disease need to consider which treatment modality they will have once their disease has progressed to end-stage kidney disease. For patients who consider haemodialysis as an option, the decision needs to be made in a timely manner so that adequate vascular access is achieved before starting dialysis. The preferred choice of access is the arteriovenous fistula (AVF) [1] because of its longevity and lower risk of complications compared with arteriovenous grafts (AVG) and catheters[2]. While the prevalence of arteriovenous fistulae use in Australia and New Zealand is 75%, the number of prevalent patients using a catheter has increased[3]. In addition the proportion of patients commencing haemodialysis with an AVF is decreasing. In Australia the proportion of patients starting dialysis with an AVF or AVG is 40% and in New Zealand it is 25%[3]. In the U.S. the proportion of patients with a maturing or functional fistula at the start of haemodialysis is 31% - 34% with 4 out of 5 patients starting dialysis with a catheter[4]. AVF use in prevalent patients is 24% in the US compared to 80% in Europe [5, 6]. Possible reasons for differences in fistula creation are patient comorbidities, access to medical care and facility preferences. Data from the Dialysis Outcome and Practice Pattern Study (DOPPS) [5] indicates that patient comorbidity is greater in the USA compared to Europe: diabetes mellitus (46 versus 22%), peripheral arterial obstructive disease (23 versus 19%), coronary artery sclerosis (37 versus 25%) and larger body mass index (25.1 versus 24.1 kg/m2). In Australia and New Zealand patients who are ____________________________________________________________________________________________________________ Vascular Access July 2012 Page 1 of 15

diabetic, female, younger than 25 years and who are referred late (first seen by a nephrologist