Timely placement of a reliable permanent Vascular access is essential for h
emodialysis care quality; National Kidney Foundation Dialysis Outcomes Qual
ity 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 acc
ess selection.
Baseline information was obtained for incident (1998) dialysis patients fro
m 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 wi
th 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 re
nal insufficiency. The most frequent initial access was a catheter (54%), f
ollowed by a fistula (29%) and a graft (16%), but selection of initial acce
ss differed significantly by patient group, with 46% of KNOWN patients rece
iving 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 lik
ely to receive a fistula as initial hemodialysis access. Studies should def
ine optimum access management when dialysis requirement is unforeseen. (C)
2000 by the National Kidney Foundation, Inc.