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Invited Commentary
May 2015

A Call to Action for Pre–End-Stage Renal Disease Care

Author Affiliations
  • 1Department of Surgery, University of Florida, Gainesville
JAMA Surg. 2015;150(5):449. doi:10.1001/jamasurg.2014.3499

Malas and colleagues1 have used the US Renal 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 arteriovenous hemodialysis 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 initiating dialysis with an AVF was 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, the use of an AVF or AVG at the onset of dialysis was associated with a lower hazard of cardiovascular- and sepsis-related mortality. Indeed, these known survival benefits provided some of the impetus for the original DOQI guidelines along with their successor, the Kidney Disease 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 choice was addressed by Malas and colleagues1 in their Discussion section and, predictably, their estimates on the additional cost (or potential savings) were staggering.

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