Access problems remain the major difficulty associated with chronic hemodialysis. Despite recent recommendations by the Dialysis Outcomes Quality Initiative (DOQI) that native arteriovenous (AV) fistulae are the optimal form of vascular access, grafts and central catheters are used by many patients. We analyzed our large Canadian regional dialysis program, which has a high prevalence of peritoneal dialysis, to examine the effect of dialysis modality choice on vascular access utilization. Point prevalence data were collected from our program in October 1997, and technique and patient survival data for the period 1990-1996 were analyzed and compared to data for the remainder of Canada from the Canadian Organ Replacement Register. Mortality rate ratios were estimated using a Poisson regression model to correct for comorbidity, age, and end-stage renal disease etiology. Of 141 in-center hemodialysis patients, 91 had an AV fistula, 1 had a polytetrafluoroethylene (PTFE) graft, and 49 were catheter-dependent. The program also included 20 home hemodialysis patients with AV fistulae, and 156 patients on peritoneal dialysis. No mortality risk differences between hemodialysis and peritoneal dialysis are seen in our center, nor are they seen for each modality in comparison with the remainder of Canada. Technique survival for peritoneal dialysis at our center was about 80% at 2 years, significantly greater than for Canada. For the program as a whole, 49% of patients used peritoneal dialysis 35% a native AV fistula, and 15% a central catheter. For Canada and the U.S.A. respectively, the comparable data were: peritoneal dialysis, 32% and 17%; native fistula, 33% and 15%; PTFE, 19% and 41%; and central catheter 16% and 27%. These data suggest that the use of peritoneal dialysis may allow reduced use of non native AV fistula access without mortality penalty.