American Board of Internal Medicine (ABIM) Certification Practice Exam

At what eGFR should patients opting for hemodialysis be referred for arteriovenous fistula (AVF) placement?

1. 20 mL/min/1.73 m2

2. 25 mL/min/1.73 m2

3. 15 mL/min/1.73 m2

4. 10 mL/min/1.73 m2

The correct answer is: 15 mL/min/1.73 m2

Patients who are considering hemodialysis should be referred for arteriovenous fistula (AVF) placement when their estimated glomerular filtration rate (eGFR) falls to around 15 mL/min/1.73 m². This timing is important for several reasons. Firstly, creating an AVF requires a lead time as the fistula needs to mature – which may take several weeks to months to develop adequate blood flow for dialysis. Referring a patient too late, when they are already experiencing significant renal failure, could result in delays in starting dialysis. Secondly, starting the process at an eGFR of 15 reflects the stage at which patients typically transition to needing dialysis soon, as most patients with advanced chronic kidney disease (CKD) begin to exhibit symptoms and complications as they approach this level of renal function. Beneficially, by referring patients at this stage, it allows healthcare providers to properly assess and manage any vascular complications and ensure optimal fistula creation, which can improve outcomes in dialysis. The other options listed would be earlier in the decline of renal function, where even though patients are nearing the need for dialysis, it may not be as immediate or pressing as at an eGFR of