We recommend that patients with advanced CKD disease (late stage 4, MDRD <20 to 25 mL/min) who have elected hemodialysis as their choice of renal replacement therapy be referred to an access surgeon in order to evaluate and plan construction of AV access (Grade 1, Level C).

1. If at the conclusion of the evaluation, upper extremity arterial and venous anatomy is adequate for an autogenous AV access, such access should be constructed as soon as possible to allow it enough time to mature and undergo further interventions that may be needed to ensure that the access is ready to be used when dialysis is initiated.
2. If a prosthetic access is to be constructed, this should be delayed until just before the need for dialysis.