Saran R et al. (2008) Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients. Ann Surg 247: 885–891

Chand DH et al. (2008) International Pediatric Fistula First initiative: a call to action. Am J Kidney Dis 51: 1016–1024

In spite of the superiority of native arteriovenous fistulae over other types of vascular access, fistula placement in US patients undergoing hemodialysis lags behind that in European patients. Two articles have sought to find reasons for and solutions to this problem.

Saran et al. analyzed questionnaires completed by specialists at 222 hemodialysis centers in 12 countries participating in the Dialysis Outcomes and Practice Patterns Study II. They found that specialists who placed more fistulae during training and those who reported “extreme or much” emphasis on vascular access creation during training were more likely to create a fistula than a graft (adjusted odds ratios 2.17 per 2-fold increase in the number of fistulae created during training, P <0.0001, and 2.74 vs “no” emphasis, P = 0.0002, respectively). Creation of at least 25 fistulae during training was associated with 34% and 40% reductions in the risks of primary and secondary fistula failure, respectively, compared with creation of 1–24 fistulae. US specialists had the lowest average number of fistulae placed during training (16) and the lowest perceived emphasis on vascular access creation during training.

Chand et al. highlight the low use of arteriovenous fistulae in US children and attempt to dispel misconceptions that discourage fistula placement in children, such as intolerance to cannulation. They introduce the International Pediatric Fistula First Initiative to advocate the creation of fistulae as the vascular access of choice in pediatric patients undergoing hemodialysis (including those who weigh <20 kg).