This is a retrospective cohort study of 2300 patients aged ≥18 years who initiated hemodialysis between 2004 and 2012 at five Canadian dialysis programs. The authors observed significantly lower mortality in individuals who underwent a predialysis fistula attempt than in those without a predialysis fistula attempt in patients aged <65 years and in the first 2 years of follow-up in those aged ≥65 years. Only 2.3% of deaths to be access-related. In summary, predialysis fistula attempt maybe associated with a lower risk of mortality. However, the excess mortality observed in patients treated with catheters does not appear to be due to direct, access-related complications but is likely the result of residual confounding, unmeasured comorbidity, or treatment selection bias. The authors will be embarking on an RCT to follow these results.