Improving access patency: pre-end-stage renal disease strategies.

Hemodialysis vascular access has emerged as a major cause of patient morbidity and cost in the end-stage renal disease (ESRD) program. It is currently estimated that the maintenance and placement of ESRD vascular access may account for up to 25% of the ESRD budget and the responsible for up to 25% of all hospital stays. The National Kidney Foundation Dialysis Outcome Quality Initiative showed that arteriovenous (AV) fistulas have a patency and cost that are significantly better than native AV grafts. Conversely, new evidence suggests that a rigorous program of prospective screening for fibromuscular dysplasia combined with intervention significantly improves AV graft longevity to levels approaching AV fistulas but at significant cost. Nonetheless, native AV fistulas remain superior, despite these advances both in terms of patency and cost. Efforts to increase the number of AV fistulas in the prevalent U.S. population are needed. New and innovative pre-ESRD strategies that lead to increased percentage of AV fistula formation are the goal for rapid improvement in access patency and decrease in access morbidity. A primary barrier to native AV fistula formation is lack of timely referral. Strategies to increase AV fistula formation require early referral to nephrology and early placement of AV fistulas.