A call to action for pre-end-stage renal disease care.

Malas and colleagues1haveused theUSRenal Data System to analyze the impact of the incident hemodialysis access type on long-term survival as a follow-up to the original Dialysis Outcome Quality Initiative (DOQI) that set a 50% incident goal for autogenous arteriovenoushemodialysis access (arteriovenous fistula [AVF]).2 Unfortunately, there has been little improvement in the incident AVF rate (14%) since the publication of these guidelines in 1997, despite the consistent observation that initiatingdialysiswith anAVFwas associated with improved long-term survival. In the current study,1 the use of an AVF at the initiation of dialysis was associated with a 35% lower mortality when compared with hemodialysis catheters (HCs), with similar benefits for patients dialyzing with a catheter while waiting for their AVF to mature (23%mortality decrease) and those with a prosthetic arteriovenous access (arteriovenous graft [AVG], 18%mortality decrease).Not surprisingly, theuseof anAVForAVGat theonset of dialysis was associated with a lower hazard of cardiovascularand sepsis-related mortality. Indeed, these known survival benefits provided some of the impetus for the originalDOQIguidelinesalongwith their successor, theKidneyDisease Outcome Quality Initiative3 and the Fistula First Breakthrough Initiative.4 These findings are very sobering and suggest that our health care system has woefully underperformed, particularly given the fact that mortality is only one of several important outcome measures (ie, morbidity, quality of life, and cost) for patients with end-stage renal disease (ESRD). The potential impact on health care costs of the incident access choicewas addressed byMalas and colleagues1 in their Discussion section and, predictably, their estimates on the additional cost (or potential savings) were staggering. The authors’ findingsmust be interpretedwith some cautionbecause it isworth emphasizing that startingdialysiswith functional AVF truly represents the best case scenario that reflects a tremendous amount of selection bias at each stage of thecareprocess includinganinvolvedpatient,earlyreferral from theprimarycarephysician toanephrologist, early referral from a nephrologist to a committed access surgeon, arterial/venous anatomy suitable for an AVF, access construction well in advance of the anticipated dialysis date, and an AVF that matures suitable for cannulation. Indeed, it is not surprising that patients with this level of pre-ESRD care (and favorable outcome in termsof a functionalAVF)haveabetter long-termoutcome. Iwould contend it is notpossible to construct anAVFon everypatientgiventheiranatomyandcomorbiditiesandwould echo the findings of the current study that AVGs are far better thanHCs and the sentiment that “fistula first” should really be “catheter last.” Interestingly, the authors’ sophisticated statistical analyses did not support the hypotheses that the low incidence of AVF was owing to poor pre-ESRD care or the patients being poor surgical candidates for an AVF. The outstanding question remains as to how these powerful data can be used to improve the incident AVF rates and, more importantly, patient outcomes. The authors have proposed changes inhealth care policy and reimbursement,with the hope of extending coverage to uninsured patients preESRD and rewarding quality care (eg, early referral to a nephrologist).Althoughsoundrecommendations, I remainskeptical that these proposed changes are practical in our rapidly shifting health care landscape. The authors have also proposed developing multidisciplinary teams that include all of the stakeholders detailed in the best-case scenario outlined here and the various hospital systems. This seems like amore realistic approach, although the challenge remains to developeffectivestrategies that leadto thedesiredoutcomewithout reproducing the failed efforts from the past decade. It is worth emphasizing that the DOQI, Kidney Disease Outcome Quality Initiative, andFistulaFirstBreakthrough Initiativehad a collective dramatic impact on the prevalence ofAVF (23% in 2003 vs 60% in 2011)5 and it has always struck me that most of these efforts were largely directed at access surgeons. Perhapsweneed to redefine the expectations andprovide gentle pressure to the nonsurgeonmembers of the pre-ESRD health care team.