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February 12, 1997

Vascular Access in Patients Receiving Hemodialysis-Reply

Author Affiliations

Brigham and Women's Hospital Boston, Mass

JAMA. 1997;277(6):456-457. doi:10.1001/jama.1997.03540300024016

In Reply.  —Dr Qureshi rightly points out that a tunneled catheter may be an optimal "bridge" to an AVF, even in the case of late referral or urgent initiation of dialysis. I agree that a trend toward use of fistulas rather than grafts might have been expected over time, in contrast to what was observed, had this catheter-to-fistula strategy been commonly used.The results of Dr Tokars and Ms Miller highlight 2 key points: prevalence of graft use over time exceeds its "incidence" at 30 days, and the marked degree of regional variation observed by Hirth et al1 is attenuated over time. These findings indicate that grafts are even more likely to be used as secondary accesses after failure of a primary graft or fistula.Drs Tesi and O'Donovan describe an alternative "philosophy," which I strongly support, in which creation of an AVF is attempted in all patients, even those with

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