Synopsis
Plan a haemodialysis fistula around the person's likely kidney-replacement journey, anatomy and priorities, then identify usable maturation or remediable failure early enough to avoid unnecessary catheter exposure.
- Choose access through a multidisciplinary shared decision that combines clinical examination, ultrasound anatomy, likely haemodialysis duration, timing, future sites and the person's priorities.
- In adults, assess fistula maturity between 2 and 6 weeks; if non-maturity persists beyond 6 weeks, investigate for correctable inflow, outflow, accessory-vein or depth problems rather than simply waiting.
- Do not cannulate by calendar alone: confirm a palpable cannulation segment, appropriate depth and course, adequate inflow and outflow, and no ischaemia, infection or unstable swelling.
Key red flags
A thrill that disappears, a new pulse-only access or abrupt loss of bruit suggests acute thrombosis and needs same-day access-team assessment.
Rest pain, weakness, sensory loss, ulceration or necrosis in the access hand indicates severe dialysis-access ischaemia requiring prompt intervention.
Rapid swelling, severe pain, falling haemoglobin, hypotension or enlarging haematoma after formation suggests bleeding or compartment-threatening pressure.
Fever, purulent drainage, spreading erythema or an exposed graft or anastomosis requires cultures, systemic assessment and urgent source-control planning.
Absent thrill, rapidly enlarging haematoma, severe swelling, rest pain, weakness or sensory change demands urgent assessment for thrombosis, bleeding, compartment pressure or severe steal.
Reasoning priorities
Assess both the access circuit and hand at each review, mapping the thrill, pulse, vein course, wound, swelling, distal perfusion and neurological function.
A continuous thrill, usable superficial segment and warm functional hand support progression; an absent thrill, focal pitch change, abnormal pulsatility or distal deficit directs urgent or targeted imaging.
Measure artery and vein diameter and quality before formation, then assess inflow, anastomosis, outflow, depth, flow, stenosis and accessory veins during maturation.
Measurements predict probability rather than give a universal pass mark. UKKA cautions that either vessel below 2.0 mm has poorer outcome and that maturity remains an individual clinical judgement.
Worked reasoning
Use when an adult's kidney trajectory and treatment choice make haemodialysis probable but dialysis has not yet started.
- Confirm kidney-replacement goals, likely timing, transplant or peritoneal options, dominant hand, work and hobbies, prior lines or devices, cardiovascular reserve and acceptable treatment burden.
- Protect potential veins, examine pulses and both arms, and arrange duplex mapping; obtain central venous imaging when history or signs suggest central outflow disease.
- Discuss distal-first fistula, graft and catheter trade-offs with the multidisciplinary team; explain poorer fistula outcome if either vessel is under 2.0 mm without treating that value as an absolute ban.
- Form the agreed access with enough lead time for healing and salvage, then check the wound, thrill and hand promptly and monitor maturation with repeated look-feel-listen assessment.
- Perform the adult maturity assessment between 2 and 6 weeks; if the fistula remains non-mature beyond 6 weeks, arrange duplex-led investigation and decide on angioplasty, accessory-vein management, superficialisation, surgical revision or a new plan.
- Verify readiness immediately before first needling, document the cannulation segment and technique, use trained support and review the first sessions for infiltration, haemostasis, delivered dialysis and evolving dysfunction.
Use after uncomplicated formation when the thrill is present, the wound is healing and the hand remains warm, comfortable and functional.