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

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 more open to upper vs forearm. If they are still not interested, I make sure they understand the risks and proceed with long-term catheter use.

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 opportunity to discuss PD.

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.