First hemodialysis access selection varies with patient acuity.

Timely placement of a reliable permanent vascular access is essential for hemodialysis care quality; National Kidney Foundation Dialysis Outcomes Quality 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 access selection. Baseline information was obtained for incident (1998) dialysis patients from 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 with 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 renal insufficiency. The most frequent initial access was a catheter (54%), followed by a fistula (29%) and a graft (16%), but selection of initial access differed significantly by patient group, with 46% of KNOWN patients receiving 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 likely to receive a fistula as initial hemodialysis access. Studies should define optimum access management when dialysis requirement is unforeseen.