A challenge for nephrologists--increasing fistula maturation rates, reducing fistula maturation time, and decreasing dialysis catheter prevalence in the United States.

Tunneled dialysis catheters are simultaneously a benefit and burden for hemodialysis patients. The infectious and vascular complications of catheters are well documented. Despite this, prevalence of catheter use in the US hemodialysis population remains high and could be due in part to increased efforts to create arteriovenous (AV) fistulas in most new end-stage renal disease patients. The editorial argues that creating fistulas instead of prosthetic grafts is the correct approach and that inadequately diagnosed and treated primary fistula failure is a major cause of excessive and prolonged catheter dependency. An understanding of AV fistula physiology and the treatable causes of primary fistula failure are key to maximizing the percentage of created fistulas that are successfully used for dialysis. Diagnosis of fistula malfunction based on history, physical examination, and hemodynamic and angiographic evaluation is discussed, and treatment strategies presented. A major emphasis is placed on early primary fistula failure recognition and intervention. It is the author's contention if adequate vein and artery are selected for initial fistula construction nearly all fistulas should eventually function adequately to support dialysis and sooner than previously appreciated by utilizing an array of percutaneous and surgical therapies. Fistula malfunction is a unique problem within the spectrum of vascular disease and therefore demands that patients are treated by physicians with demonstrated expertise and experience.