Table 1.

Timing of hemodialysis vascular access creation

Organization	Country	Recommendation
National Kidney Foundation Kidney Disease Outcomes Quality Initiative	United States	“Patients with a glomerular filtration rate (GFR) less than 30 ml/min/1.73 m2 (CKD stage 4) should be educated on all modalities of kidney replacement therapy (KRT) options, including transplantation, so that timely referral can be made for the appropriate modality and placement of a permanent dialysis access, if necessary … A fistula should be placed at least 6 months before the anticipated start of HD treatments. This timing allows for access evaluation and additional time for revision to ensure a working fistula is available at initiation of dialysis therapy … A graft should, in most cases, be placed at least 3 to 6 weeks before the anticipated start of HD therapy. Some newer graft materials may be cannulated immediately after placement.”
Canadian Society of Nephrology	Canada	“Set specific targets for tasks during CKD Stages 3, 4, and 5 management according to the rate of decline of eGFR: (a) Assuming a usual rate of decline of 2–5 ml/min/yr, modality education should usually begin at eGFR=30 ml/min, modality decisions should usually be finalized by eGFR=20 ml/min, and that those who choose HD (and who are expected to survive long enough and are suitable), should usually be referred to a vascular surgeon for consideration/evaluation of AVF when eGFR=15–20 ml/min (as per 2006 CSN guideline). (b) In patients whose rate of decline of eGFR over time is greater than 5 ml/minute/year, these tasks should be undertaken earlier than proposed before … Assuming that local resources are available, we recommend that if and when patients reach eGFR=15 ml/minute and are unable or unwilling to make a modality decision, consideration should be given to refer suitable patients to the VA surgical team for assessment concerning possible dialysis access options … Note that this recommendation is about when to consider referral to the surgeon for evaluation, and does not contemplate when vascular surgery is to be scheduled.”
The Renal Association	United Kingdom	“Vascular access planning should commence at some point after an individual reaches CKD stage 4 … exact timing of placement of vascular access will be determined by rate of decline of renal function, co-morbidities and by the surgical pathway”
National Health and Medical Research Council	Australia	“No recommendations possible based on Level I or II evidence.” Suggestions for clinical care (suggestions are on the basis of levels 3 and 4 evidence): all patients, especially those with comorbid conditions, should be referred to a vascular access surgeon well in advance of the anticipated need for hemodialysis. The exact timing depends on patient-related factors and local facilities
Japanese Society for Dialysis Therapy	Japan	“VA construction should be considered when eGFR is less than 15 ml/min/1.73 m2 (CKD stages 4 and 5) as well as taking into account clinical conditions. In patients with diabetic nephropathy, who have a tendency to show overhydration, VA construction should be considered at a higher eGFR … Anticipating the start of hemodialysis from the results of various laboratory tests and clinical symptoms, ideally the AVF should be constructed at least 2 to 4 weeks before the initial puncture. In the case of an AVG, the time from construction to initial puncture should be 3 to 4 weeks.”

HD, hemodialysis; AVF, arteriovenous fistula; CSN, Canadian Society of Nephrology; VA, vascular access; AVG, arteriovenous graft.