How do you approach recommending an AVF for a patient with advanced CKD who is concerned about the cosmetic appearance of the fistula?

My approach is usually 2-fold.

• First, I try to emphasize the medical benefits of an AVF over a catheter.
• Second, I point out that the catheter is also the most aesthetically appealing option to have.

I then go over possible solutions of covering the AVF (sleeves, etc.).

This could also be a good ...

Assuming that the patient is either not interested or not suitable for peritoneal dialysis and they do not have a potential living donor, I discuss the risks/benefits of AVF vs a tunneled catheter. I offer upper arm AVFs to these patients (even if forearm vessels are adequate), as sometimes they are...

I have encountered this scenario in the past. I was finally able to convince the patient to receive an AV graft, as it is cosmetically less risky to develop aneurysms. However, it took a couple of years. Persistence may be the best option.