Change Concept 3: Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement

When possible, coordinate chronic kidney disease patient care so that patients will be referred early to surgeons specifically for AV fistula evaluation, including vein mapping where indicated, allowing sufficient lead-time for AV fistula maturation. Studies show that mapping vessels can significantly increase the incidence of successful AV fistulae. Establish the understanding with your surgeons that they will contact you before placing anything other than an AV fistula. Where timing is such that a temporary access must be placed (e.g., catheter), arrange for evaluation (and placement, if feasible) of an AV fistula during the initial hospitalization. Primary care physicians utilize ESRD/CKD referral criteria to ensure timely referral of patients to nephrologists.

• Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery referral.
• Nephrologist refers for vessel mapping where feasible, prior to surgery referral.
• Nephrologist refers patients to surgeons for “AVF only” evaluation, no later than Stage 4 CKD (GFR<30). Surgery scheduled with sufficient lead-time for AVF maturation.
• Nephrologist defines AVF expectations to surgeon, including vessel mapping (if not already performed).
• If timely placement of AVF does not occur, nephrologist ensures that patient receives AVF evaluation and placement at the time of initial hospitalization for temporary access (e.g. catheter).

Changes for Improvement

Refer Patients for Vessel Mapping

Nephrologists should refer patients for vessel mapping (identification of vessel anatomy) where feasible, ideally prior to surgery referral.  Doppler ultrasound or alternate technique should be used to search for suitable vessels that may be too deep to be identified on physical exam.  Numerous studies have shown that vessel mapping identifies vessels suitable for an AV fistula in the majority of patients where physical exam alone classified the patient as not being a candidate for an AV fistula.

Schedule Surgery with Sufficient Lead-Time for AVF Maturation

In order to schedule surgery with sufficient lead-time for AV fistula maturation, nephrologists should refer patients to surgeons for “AVF only” evaluation no later than Stage 4 CKD (GFR<30).

Communicate AVF Expectations (including Vessel Mapping) to Surgeons

Nephrologists should establish an understanding with surgeons that all patients should be fully evaluated for the possibility of an AV fistula, including vessel mapping where necessary.