Much of the literature on AVF placement has reported rather disappointing results with most series demonstrating maturation failure rates of 40–45 % [8–11] [12] with a single recent series slightly better at only 30 % [13]. Added to that, some patients undergoing AVF placement in the preemptive strategy may never require HD and are exposed to unnecessary morbidity. Risk factors for failure of AVF maturation are often not modifiable. This includes advanced age, female gender, diabetes, and nonwhite race. The size of the vein and the creation of upper versus forearm AVFs (likely interrelated) have some potential modification in planning with targeting a certain extremity/vein, etc. Current recommendations for acceptable vein diameter range from 2.5 to 3 mm with veins 4 mm or greater having the best chance of AVF success [14]. If, however, the plan was to only perform AVFs on younger nondiabetic white males with large veins, the fraction of patients undergoing AVF would be minimal, and although maturation success would be much higher, the percent of incident patients using an AVF at HD onset would remain very low.

These contributions can be seen in the regional variability of prevalent AVF usage in the FFBI data. Regions such as Colorado, Oregon, New Hampshire, Rhode Island, and Washington are at or above the target of two thirds prevalent AVF usage. Conversely, regions such as South Carolina, Virginia, District of Columbia, Alabama, and Arkansas are only slightly above 50 % prevalent usage. It would seem safe to assume that much of these differences are due to non-modifiable issues within the respective populations they are caring for rather than any inherent skill set differences between the providers. However, none of these issues are addressed in the current guidelines or performance metrics.

The major morbidity of AVF creation is lack of maturation and failure to mature for use, necessitating additional procedures as stated above. Other issues include steal in 1–8 % of patients [15, 16] arm edema due to unmasked central venous stenosis, and rarely ischemic monomelic neuropathy [17]. All of these require secondary procedures up to and including abandoning the access. The incidence of these complications increases with age and diabetes.