Fistula First: myth vs. fact.

It is estimated that there are fewer than one million patients with Stages 4 and 5 CKD not on dialysis. Most of these patients have regular encounters with the health care system because of diabetes, hypertension, and other diseases of aging. Many of these patients are not under the ongoing care of a nephrologist, but could be if the appropriate triggers for nephrology referral are established at the system level. Even among patients who have been cared for by a nephrologist for >12 months prior to the onset of dialysis, the incident AVF rate is only around 25%. This is an embarrassingly low rate and reflects an opportunity for the nephrologist to emerge as a leader to drive the system changes that will promote timely referral and AVF placement. A doubling of the incident AVF rate to 50%, achievable with effective system change, is the best path to reach a prevalent AVF rate of 66%.