Unraveling the realities of vascular access: The Network 11 experience

Arteriovenous (AV) fistulae are well recognized as the preferred vascular a ccess for hemodialysis, yet national data show that only 23% of patients us ed an AV fistula in 1997. To identify barriers to the placement of native A V fistulae, the Renal Network of the Upper Midwest, Inc. (End-Stage Renal D isease [ESRD] Network 11) initiated a vascular access project to look at th e process of referral for patients beginning hemodialysis in the first 6 mo nths of 1999. Of these patients, 63% began hemodialysis with a catheter as the only access, 22% had an AV fistula placed (but only 14% used an AV fist ula for their first dialysis treatment), and 15% began with a graft. About 40% of patients were referred to a nephrologist less than 1 month before di alysis, allowing little chance for permanent access placement. Yet 27% of p atients used a catheter on the first hemodialysis treatment and were seen b y a nephrologist more than 1 month before starting dialysis, indicating the presence of an opportunity to improve. At 6 months after initiation of dia lysis, 25% of patients who began dialysis using a catheter were using an AV fistula and 35% were using a graft. Network 11 plans to use this informati on to promote early referral of patients to a nephrologist and subsequent p rompt referral of such patients to a vascular surgeon. Other activities to improve vascular access management are also indicated. (C) 2000 by the Nati onal Kidney Foundation, Inc.