Background: The Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines encourage increasing the proportion of arteriovenous fistulae among incident hemodialysis patients. Achieving optimal outcomes requires predialysis out-patient follow-up by a nephrologist, predialysis placement of a vascular access, and adequate maturation of the vascular access. Methods: We assessed the effect of clinical factors on predialysis vascular access management in all incident hemodialysis patients at a single institution during a 2-year period. Results: Of 157 patients initiating dialysis therapy from January 1, 2001, to December 31, 2002, a total of 73.2% had predialysis follow-up by a nephrologist, 46.5% had predialysis vascular access surgery, and 35.0% initiated their first dialysis session with a permanent access. Among patients using a permanent access on their first dialysis session, 67.3% used a fistula. Patients with diabetes were more likely than those without diabetes to have predialysis nephrology follow-up (81.5% versus 61.5%; P = 0.005), undergo predialysis vascular access surgery (56.5% versus 32.3%; P = 0.003), and initiate their first dialysis session with a fistula or graft (43.5% versus 23.1%; P = 0.008). Duration of predialysis nephrology follow-up was similar between patients with and without diabetes (median, 412 versus 300 days; P = 0.27). Patient age, sex, and race were not predictive of predialysis access management. Conclusion: Despite attempts to follow the K/DOQI guidelines, 65% of incident hemodialysis patients initiated their first dialysis treatment with a catheter. Patients with diabetes were significantly more likely to have predialysis follow-up by a nephrologist and thus more likely to initiate their first dialysis session with a permanent access. Emphasis on early referral of patients with chronic kidney disease without diabetes to nephrologists may increase fistula use among incident hemodialysis patients. © 2004 by the National Kidney Foundation, Inc.