title: Optimizing AVF creation prior to dialysis start: the role of predialysis renal replacement therapy choices.
abstract: BACKGROUND
  In British Columbia, multidisciplinary predialysis clinics encourage patients to consider independent modalities of renal replacement therapy (RRT) such as peritoneal dialysis (PD) 'first'. Despite up to 50% of patients choosing PD, PD incidence rates are ~30%. We explored the relationship between predialysis RRT choice and arteriovenous fistula (AVF) creation prior to hemodialysis (HD) start with particular focus on the group of patients who despite PD choice actually commence HD, and thus may contribute to 'suboptimal' HD starts without AVF creation.
  
  
  METHODS
  We conducted a retrospective cohort study of all patients starting dialysis between 31 December, 2006 and 31 December 2008 in the province of British Columbia. Inclusion criteria were >3 months predialysis nephrology follow-up, at least one predialysis RRT education session and maintenance on dialysis for a minimum of 3 months (to ensure chronic dialysis). Patients with any prior history of RRT were excluded.
  
  
  RESULTS
  There were 508 patients included in the study: 127 (25%) patients chose HD, 114 (22%) PD, 13 (3%) pre-emptive transplant, 5 (1%) conservative management and 249 (49%) had no documented modality decision. Of those who chose HD, 94% commenced HD. For those who chose PD, 64% commenced PD and 36% HD. In the undecided group, 68% started HD and 32% PD. For those patients who chose PD predialysis, the presence of cardiovascular disease [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.02-5.43] and lower serum albumin levels (OR 0.92, 95% CI 0.86-0.98) were associated with failure to commence PD. Predialysis AVF creation rates were 79% of those who chose and started HD, 39% of those who chose PD but started HD and 50% of those in the undecided group who commenced HD.
  
  
  CONCLUSIONS
  AVF creation rates prior to HD start were lower in those patients with no documented dialysis modality choice and in those who failed to commence PD. Cardiovascular disease and lower serum albumin levels were associated with failure to start PD. Further work to ensure the efficacy of RRT modality choice pathway and to better predict those patients who will fail to commence PD is necessary, so that dialysis start can be 'optimized' with AVF creation in high-risk groups.
authors.affiliation: Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada. jennifer.hanko@belfasttrust.hscni.net
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hanko
authors.forename: Alexandra
authors.initials: A
authors.lastname: Romann
authors.forename: Paul
authors.initials: P
authors.lastname: Taylor
authors.forename: Michael
authors.initials: M
authors.lastname: Copland
authors.forename: Monica
authors.initials: M
authors.lastname: Beaulieu
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000379:methods*; D001955:British Columbia; D002755:Choice Behavior; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000379:methods / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000379:methods / Q000706:statistics & numerical data; D017582:Renal Replacement Therapy / Q000379:methods* / Q000706:statistics & numerical data; D012189:Retrospective Studies