title: First hemodialysis access selection varies with patient acuity.
abstract: Timely placement of a reliable permanent vascular access is essential for hemodialysis care quality; National Kidney Foundation Dialysis Outcomes Quality Improvement (NKF-DOQI) guidelines emphasize native arterio-venous (AV) fistulae as preferred access for incident patients. As part of Network One's Vascular Access Quality Improvement Project (QIP) we investigated whether patients' course to end-stage renal disease (ESRD) influenced vascular access selection. Baseline information was obtained for incident (1998) dialysis patients from 6 centers participating in the Network QIP. Patients were subdivided into 3 predefined clinical groups: KNOWN (known chronic renal disease, seen by a nephrologist, with predictable progression to ESRD), CRISIS (KNOWN but with unanticipated medical crisis precipitating ESRD), and UNKNOWN (not known to have chronic renal insufficiency or never seen by a nephrologist before developing ESRD). Two hundred forty patients were identified (median age 69.9, 42% diabetic). Only 43% of the entire population experienced an orderly progression to renal insufficiency. The most frequent initial access was a catheter (54%), followed by a fistula (29%) and a graft (16%), but selection of initial access differed significantly by patient group, with 46% of KNOWN patients receiving a fistula (P <.001). After 2 months of dialysis, the initial access supported dialysis in only 53.7% of the KNOWN patients, and in 59.4% and 45.7% of the CRISIS and UNKNOWN patients, respectively. We conclude that unpredicted, new ESRD patients are common and are less likely to receive a fistula as initial hemodialysis access. Studies should define optimum access management when dialysis requirement is unforeseen.
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA.
authors.forename: A L
authors.initials: AL
authors.lastname: Friedman
authors.forename: C
authors.initials: C
authors.lastname: Walworth
authors.forename: C
authors.initials: C
authors.lastname: Meehan
authors.forename: H
authors.initials: H
authors.lastname: Wander
authors.forename: D
authors.initials: D
authors.lastname: Shemin
authors.forename: W
authors.initials: W
authors.lastname: DeSoi
authors.forename: J
authors.initials: J
authors.lastname: Kitsen
authors.forename: C
authors.initials: C
authors.lastname: Hill
authors.forename: C
authors.initials: C
authors.lastname: Lambert
authors.forename: D
authors.initials: D
authors.lastname: Mesler
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data; D001807:Blood Vessel Prosthesis; D002408:Catheters, Indwelling / Q000706:statistics & numerical data; D014487:Centers for Medicare and Medicaid Services, U.S.; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D006435:Renal Dialysis; D012720:Severity of Illness Index; D017749:Total Quality Management; D014481:United States