The KDOQI Work Group and Dr. Michelle L. Robbin from the University of Alabama at Birmingham, offer valuable guidelines for successful hemodialysis cannulation of fistulas in end-stage-renal-disease (ESRD) patients. It is recommended that a 4 mm or greater vessel diameter and flow of 500 mL/min or greater is needed to support successful hd cannulation and dialysis blood flow rates. Ultrasound is not needed for cannulation. Also suggested is the following Rule of Sixes:

1. Flow in the fistula should be greater than 600 mL/min;
2. The diameter of the fistula should be at least 6 mm;
3. The fistula should be no more than 6 mm deep;
4. The fistula should have discernible margins;
5. The fistula should be ready for use within six weeks.

The goal of the Rule of Sixes is to guide a Dialysis Access Care team in the four- to six-week maturation assessment of a new vascular access. The measurements are all obtainable with a standard ultrasound technique available in many surgeons’ offices. If an AV fistula is not reaching the needed vessel diameter the surgeon and/or interventionalist may decide to use angioplasty on the vein. If the AV fistula is > 6 mm deep, the surgeon may need to superficialize the vein to the skin so that the vessel can be cannulated. See: http://esrdncc.org/en/resources/patients/access-monitoring/