We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Invited Commentary |

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

Thomas S. Huber, MD, PhD1
[+] Author Affiliations
1Department of Surgery, University of Florida, Gainesville
JAMA Surg. 2015;150(5):449. doi:10.1001/jamasurg.2014.3499.
Text Size: A A A
Published online


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.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles