title: Predialysis care and dialysis outcomes in hemodialysis patients with a functioning fistula.
abstract: OBJECTIVE
  Predialysis care has been associated with improved first-year outcomes. We investigated types of predialysis care associated with improved patient outcomes in patients initiating dialysis with a fistula and at least 2 years of predialysis care.
  
  
  METHODS
  In this retrospective cohort of incident hemodialysis patients with ≥2 years of Medicare coverage before dialysis initiation, care patterns and patients were determined using Medicare claims. Fistula use at initiation was ascertained from the Medical Evidence Report.
  
  
  RESULTS
  Patients aged ≥67 years who initiated hemodialysis with a fistula (n = 14,459) differed demographically and clinically from patients who initiated with other vascular access types; however, 55% had diabetes, 28% heart failure, and 40% ischemic heart disease. In the year preceding initiation, 88% of these patients visited a nephrologist, 66% a cardiologist, 9% an endocrinologist, and 3% a dietician; most underwent routine laboratory measurements. In the first year of dialysis, 50% were hospitalized and 1.3% underwent transplant; the mortality rate remained constant (∼20 per 100 patient-years). Of predialysis care factors evaluated, only fistula placement more than 1 month before dialysis initiation was associated with lower hospitalization and mortality risk and greater likelihood of transplant. Other potentially modifiable factors included more contact with cardiologists and endocrinologists.
  
  
  CONCLUSIONS
  Patients initiating dialysis with a functioning fistula appear to receive substantial predialysis preparation. This selected population does not show the excess mortality risk often observed early in dialysis treatment. Earlier fistula placement and referral to cardiology and endocrinology appear to be important aspects of predialysis care.
authors.affiliation: Minneapolis VA Health Care System, University of Minnesota, Minneapolis, Minn., USA.
authors.forename: Areef
authors.initials: A
authors.lastname: Ishani
authors.forename: David T
authors.initials: DT
authors.lastname: Gilbertson
authors.forename: Deborah
authors.initials: D
authors.lastname: Kim
authors.forename: Brian D
authors.initials: BD
authors.lastname: Bradbury
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Collins
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D048909:Diabetes Complications / Q000628:therapy; D005260:Female; D005402:Fistula / Q000503:physiopathology*; D006333:Heart Failure / Q000150:complications / Q000401:mortality; D006801:Humans; D008297:Male; D006278:Medicare; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications / Q000401:mortality; D006435:Renal Dialysis / Q000379:methods*; D051437:Renal Insufficiency / Q000401:mortality* / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States