Timing of nephrologist referral and arteriovenous access use: The CHOICE study

Recent clinical practice guidelines recommend the creation of an arterioven ous (AV) vascular access (ie, native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication -prone dialysis catheters. We report on the association of referral to a ne phrologist with duration of dialysis-catheter use and type of vascular acce ss used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outco mes in Caring for End-Stage Renal Disease Center Study. Patients who report ed being seen by a nephrologist at least 1 month before starting hemodialys is therapy (75%) were more likely than those referred later to use an AV ac cess at initiation (39% versus 10%; P < 0.001) and 6 months after starting hemodialysis therapy (74% versus 56%; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a me dian of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis th erapy, respectively (P trend < 0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients refer red later to use an AV fistula, rather than a synthetic graft, as their fir st AV access (45% versus 31%; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, Insurance coverag e, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist subst antially increases the likelihood of dialysis-catheter use at the initiatio n of hemodialysis therapy and is associated with prolonged catheter use. Re gardless of the time of referral, only a minority of patients used an AV ac cess at the initiation of treatment, and greater than 25% had not used an A V access 6 months after Initiation. Thus, further efforts to improve both r eferral patterns and preparation for dialysis after referral are needed. (C ) 2001 by the National Kidney Foundation, Inc.