Type Of Hemodialysis Vascular Access Research Articles

Effect of Hemodialysis Vascular Access Type on Serum Interleukin-6 (IL-6) Levels in ESRD

Effect of Hemodialysis Vascular Access Type on Serum Interleukin-6 (IL-6) Levels in ESRD

A randomized pilot study to evaluate graft versus fistula vascular access strategy in older patients with advanced kidney disease: results of a feasibility study

BackgroundAlthough older adults encompass almost half of patients with advanced chronic kidney disease, it remains unclear which long-term hemodialysis vascular access type, arteriovenous fistula or arteriovenous graft, is optimal with respect to effectiveness and patient satisfaction. Clinical outcomes based on the initial AV access type have not been evaluated in randomized controlled trials. This pilot study tested the feasibility of randomizing older adults with advanced kidney disease to initial arteriovenous fistula versus graft vascular access surgery.MethodsPatients 65 years or older with pre-dialysis chronic kidney disease or incident end-stage kidney disease and no prior arteriovenous vascular access intervention were randomized in a 1:1 ratio to undergo surgical placement of a fistula or a graft after providing informed consent. Trial feasibility was evaluated as (i) recruitment of ≥ 70% of eligible participants, (ii) ≥ 50 to 70% of participants undergo placement of index arteriovenous access within 90 to 180 days of enrollment, respectively, (iii) ≥ 80% adherence to study-related assessments, and (iv) ≥ 70% of participants who underwent index arteriovenous access placement will have a follow-up duration of ≥ 12 months after index surgery date.ResultsBetween September 2018 and October 2019, 81% (44/54) of eligible participants consented and were enrolled in the study; 11 had pre-dialysis chronic kidney disease, and 33 had incident or prevalent end-stage kidney disease. After randomization, 100% (21/21) assigned to arteriovenous fistula surgery and 78% (18/23) assigned to arteriovenous graft surgery underwent index arteriovenous access placement within a median (1st, 3rd quartile) of 5.0 (1.0, 14.0) days and 13.0 (5.0, 44.3) days, respectively, after referral to vascular surgery. The completion rates for study-specific assessments ranged between 40.0 and 88.6%. At median follow-up of 215.0 days, 5 participants expired, 7 completed 12 months of follow-up, and 29 are actively being followed. Assessments of grip strength, functional independence, and vascular access satisfaction were completed by > 85% of patients who reached pre-specified post-operative assessment time point.ConclusionsResults from this study reveal it is feasible to enroll and randomize older adults with advanced kidney disease to one of two different arteriovenous vascular access placement surgeries. The study can progress with minor protocol adjustments to a multisite clinical trial.Trial registrationClinical Trials ID, NCT03545113.

Current state of dialysis access management in Korea.

The prevalence rate and the incidence rate of hemodialysis and functioning kidney transplant recipients have continuously increased; on the contrary, those of peritoneal dialysis have continuously decreased since 2006. Dialysis patients have been getting older and have been maintained on dialysis longer. Diabetic nephropathy was the leading cause of end stage renal disease. The type of hemodialysis vascular access has been stable during the last 5 years (arteriovenous fistulas 76%, arteriovenous grafts 16%, central venous catheters 8% at 2016). Peritoneal dialysis catheter was mostly inserted surgically (67%), and swan neck straight tip peritoneal dialysis catheter was the most commonly used (48%). Vascular access was managed by radiologists and surgeons, and the management was fragmented among them in the past. However, since the nephrologists became interested in and knowledgeable about the vascular access, they began to play roles in vascular access management. Vascular access has been mostly created by vascular surgeons (≈60%); tunneled central venous hemodialysis catheter insertion and endovascular intervention such as percutaneous transluminal angioplasty (PTA) and thrombectomy have been mostly performed by radiologists (≈70%). Tunneled hemodialysis catheter insertion and endovascular intervention by nephrologists have slowly but consistently increased. Recently, the number of central venous hemodialysis catheter insertion has decreased, and tunneled hemodialysis catheter has been inserted more than non-tunneled hemodialysis catheter, indicating that vascular access has been created timely and the vascular access team has been educated about and following international guidelines.

Complications From Tunneled Hemodialysis Catheters: A Canadian Observational Cohort Study

Clinical practice guidelines discourage the use of central venous catheters (CVCs) for vascular access in dialysis. However, some patients have inadequate vessels for arteriovenous fistula creation or choose to use a dialysis catheter. The risks associated with CVC use and their relationship to patient age are poorly characterized. Observational retrospective cohort study. Cohort of 1,041 patients older than 18 years from 5 Canadian dialysis programs who initiated outpatient maintenance hemodialysis therapy with a tunneled CVC between 2004 and 2012 and who had no creation of an arteriovenous fistula or arteriovenous graft. Age, sex, body size, initiating dialysis therapy in the hospital, and comorbid conditions. CVC-related procedures, hospitalization, and death. Complications were reported as a cumulative risk at 1 and 2 years. Cox proportional hazards regression for recurrent events was used to evaluate risk factors for study outcomes. At 1 year, risks for CVC-related bacteremia, malfunction, and central stenosis were 9%, 15%, and 2%, respectively. Risks for any CVC-related complication at 1 and 2 years were 30% and 38%, respectively. Death related to CVC complications occurred in 6 of 1,041 (0.5%) patients. Compared with patients younger than 60 years, patients aged 70 to 79 and those 80 years or older experienced lower rates of CVC complications: HRs of 0.67 (95% CI, 0.52-0.85; P= 0.001) and 0.69 (95% CI, 0.52-0.92; P= 0.01), respectively. This Canadian dialysis population may not be representative of populations in other countries. CVC use was not compared with other types of hemodialysis vascular access. Approximately one-third of hemodialysis patients who used tunneled CVCs during 1 to 2 years experienced complications. Bacteremia occurred in ∼9% of patients at 1 year and were the most common cause of CVC-related hospitalizations. CVC-related death was infrequent. This information could be used to communicate the risk for CVC complications to patients treated with this type of hemodialysis vascular access.

Smooth Muscle Nitric Oxide Responsiveness and Clinical Maturation of Hemodialysis Arteriovenous Fistulae

The arteriovenous fistula is the preferred type of hemodialysis vascular access for patients with end-stage renal disease, but a high proportion of newly created fistulas fail to mature for use. Stenosis caused by neointimal hyperplasia often is present in fistulas with maturation failure, suggesting that local mechanisms controlling vascular smooth muscle cell (SMC) migration and proliferation are important contributors to maturation failure. SMCs cultured from explants of vein tissue obtained at the time of fistula creation from 19 patients with end-stage renal disease were studied to determine whether smooth muscle responsiveness to nitric oxide is associated with fistula maturation outcomes. Nitric oxide-induced inhibition of smooth muscle cell migration, but not proliferation, was greater in cells from patients with subsequent fistula maturation success than from patients with subsequent fistula maturation failure (mean inhibition percentage, 17 versus 5.7, respectively; P=0.035). Impaired nitric oxide responsiveness was associated with oxidation of the calcium regulatory protein, sarcoplasmic/endoplasmic reticulum calcium ATPase (SERCA), and was reversed by overexpressing SERCA (1.8-fold increase in inhibition, P=0.0128) or down-regulating Nox4-based NADPH oxidase (2.3-fold increase in inhibition; P=0.005). Our data suggest that the nitric oxide responsiveness of SMC migration is associated with fistula maturation success and raises the possibility that therapeutic restoration of nitric oxide responsiveness through manipulation of local mediators may prevent fistulamaturation failure.

Variations in outcomes of hemodialysis vascular access by race/ethnicity in the elderly

ObjectivePrevalence of end-stage renal disease, modality of treatment, and type of hemodialysis vascular access used varies widely by race/ethnicity in the United States, but outcomes of hemodialysis vascular access by race/ethnicity are poorly described. The objective of this study is to evaluate variations in outcomes of hemodialysis vascular access in the elderly by race/ethnicity. MethodsMedicare outpatient, inpatient, and carrier files were queried from 2006 to 2011 for beneficiaries that were age ≥66 years and dialysis-dependent at time of index fistula/graft creation, qualified for Medicare by age only, and were continuously enrolled in Medicare 12 months before and after index fistula/graft creation. Primary outcome measures were early vascular access failure and 12-month failure-free survival, specifically, the variation in the difference between fistula and graft in non-White vs White race/ethnicity groups. ResultsFistulas comprised a smaller proportion of index procedures performed in Blacks (65.9%; P < .001) and Asians (71.4%; P < .001), compared with Whites (78.0%) with no difference in Hispanics (78.7%; P = .59). Incidence of early failure after graft vs fistula was Whites, 34.9% vs 43.5% (P < .001), Blacks, 32.9% vs 49.1% (P < .001), Asians, 30.8% vs 40.5% (P = .014), and Hispanics 35.2% vs 43.2% (P = .005). The difference in early failure after fistula vs graft in Blacks was significantly larger than the difference in Whites (P < .001). The 12-month failure-free survival after index graft vs fistula was Whites 41.9% vs 38.9% (P = .008), Blacks 48.5% vs 37.3% (P < .001), Asians 51.6% vs 45.2% (P = .98), and Hispanics 51.9% vs 42.2% (P < .001). The difference in 12-month failure-free survival after graft vs fistula in Blacks and in Hispanics was larger than the difference in Whites (P < .001 and P = .02, respectively). ConclusionsOutcomes of fistulas vs grafts in the elderly vary significantly by race/ethnicity. The decreased risk of early failure after graft vs fistula creation is larger in Blacks compared with Whites. The higher failure-free survival at 12 months after graft vs fistula creation is larger in Blacks compared with Whites and trends toward being larger in Hispanics compared with Whites.

Risk factors associated with inadequate veins for placement of arteriovenous fistulas for hemodialysis

An arteriovenous fistula (AVF) between the radial artery and cephalic vein at the wrist is the preferred type of hemodialysis vascular access. However, in the practice of access placement, we are aware that some patients fail to form the standard forearm radial-cephalic AVF, owing to naturally small veins or acquired abnormal lesions of the veins. To identify the risk factors for failure to form the standard AVF, we examined 305 consecutive patients who underwent first-time access surgery at our hospital from January 2006 to December 2010. We compared the patients' characteristics between those having normal vessels and successfully forming the standard AVF, and those having apparently abnormal vessels and thus forming alternative types of access instead. Histories of major and minor surgery were specifically evaluated, assuming that surgical procedures in the past could potentially damage the superficial veins. We created 207 standard and 98 alternative accesses during the period and found that significantly more patients with alternative accesses (31%) had undergone major surgery of a variety of specialties, in comparison with those with the standard AVF (15.0%). Multivariate logistic analysis revealed that a history of major surgery (OR=2.39, 95%CI 1.29-4.47, p=0.006) and female gender (OR=1.87, 95%CI 1.10-3.20, p=0.02) were independent risk factors associated with failure to construct the standard AVF. Our results indicate that previous surgery can damage the superficial veins and cause venous abnormality, which makes construction of the standard AVF difficult. We propose that care should be taken to preserve the superficial veins when patients for whom dialysis therapy is a future possibility undergo surgical procedures, especially invasive ones.

Smooth muscle nitric oxide responsiveness predicts clinical maturation of hemodialysis fistulae

The arteriovenous fistula is the preferred type of hemodialysis vascular access for patients with end‐stage renal disease, but 50% of newly created fistulas fail to mature adequately for use. Stenosis due to neointimal hyperplasia is present in a large proportion of fistulae with maturation failure suggesting that local mechanisms controlling vascular smooth muscle cell (SMC) migration are important contributors to maturation failure. Our objective is to manipulate local factors present in the vein at the time of fistula surgery in order to prevent maturation failure. Using SMC explants from vein tissue obtained at the time of fistula creation from patients enrolled in the NIH Hemodialysis Fistula Maturation Study, we find that among patients with subsequent fistula maturation failure, •NO inhibits SMC migration significantly less. Using strategies initially developed in animal models, we find that impaired •NO inhibition is associated with oxidation of the calcium regulatory protein, sarcoplasmic/endoplasmic reticulum calcium ATPase (SERCA), and can be reversed by overexpressing SERCA or by down‐regulating Nox4 NADPH oxidase. Our data suggest that SMC •NO responsiveness may be predictive of fistula maturation outcome and that therapeutic restoration of •NO responsiveness through manipulation of local factors may prevent fistula maturation failure.Funding: R21DK084390 and R01 HL31607

Role of the Hemodialysis Vascular Access Type in Inflammation Status and Monocyte Activation

The aim of this study was to ascertain the role of different vascular access types in inflammatory status, monocyte activation, and senescence in hemodialysis patients. We recruited 126 hemodialysis patients, including 51 with arterovenous fistula (AVF), 32 with arterovenous graft (AVG), and 43 with tunneled cuffed catheters (TCC). In dialysis patients enrolled in the study and in a control group of 40 healthy subjects, we measured the serum levels of albumin, CRP, IL-6, and TNF-a, the expression of CD14, CD44, and CD32 on monocyte surface, and the percentage of monocytes exhibiting a senescent phenotype (CD14+CD32+). The patients with AVG compared to those with AVF had: a) higher levels of CRP and TNF-a; b) increased expression of CD14 and CD32 on monocyte surface, with no difference in CD44 expression; c) no difference in the percentage of CD14+CD32+ monocytes. In the comparison of TCC vs. AVF group, we observed significantly higher values of: a) circulating inflammatory markers (CRP, IL-6, TNF-a); b) monocyte surface expression of cellular activation markers (CD14, CD44 and CD32); c) relative count of CD14+CD32+ monocytes. When comparing TCC vs. AVG group, we found: a) no difference in serum levels of CRP, IL-6, and TNF-a; b) no difference in the expression of CD14, CD44, and CD32 on monocyte surface; c) no difference in the percentage of CD14+CD32+ monocytes. These results suggest that the use of AVG and TCC for dialysis vascular access is associated with serological and cellular indexes of inflammatory reaction, also resulting in a higher degree of monocyte activation and senescence.

Choice of Vascular Access among Incident Hemodialysis Patients

Arteriovenous fistulas (AVFs) are widely accepted as the preferred hemodialysis vascular access type. However, supporting data have failed to consider morbidity and mortality incurred during failed creation attempts and may therefore overstate potential advantages. This study compares survival, quality-adjusted survival, and costs among incident hemodialysis patients after attempted placement of AVFs or arteriovenous grafts (AVGs). Analogous Markov models were created, one each for AVF and AVG. Patients entered consideration at the time of first access creation, contemporaneous with dialysis initiation. Subsequent outcomes were determined probabilistically; transition probabilities, utilities, and costs were gathered from published sources. To ensure comparability between AVFs and AVGs, the timing and likelihood of access maturation were measured in a contemporary cohort of incident hemodialysis patients. Mean (SD) overall survival was 39.2 (0.8) and 36.7 (1.0) months for AVFs and AVGs, respectively: difference (95% confidence interval [CI]) 2.6 (1.8, 3.3) months. Quality-adjusted survival was 36.1 (0.8) and 32.5 (0.9) quality-adjusted life months (QALMs) for AVFs and AVGs, respectively: difference (95% CI) 3.6 (2.8, 4.3) QALMs. The incremental cost-effectiveness ratio (95% CI) for AVFs relative to AVGs was $446 (-6023, 6994) per quality-adjusted life year saved. AVFs are associated with greater overall and quality-adjusted survival than AVGs. Observed differences were much less pronounced than might be expected from existing literature, suggesting that prospective identification of patients at high risk for AVF maturational failure might enable improvements in health outcomes via individualization of access planning.

Relationship between Clinical Outcomes and Vascular Access Type among Hemodialysis Patients with Staphylococcus aureus Bacteremia

The association between hemodialysis vascular access type, costs, and outcome of Staphylococcus aureus bacteremia (SAB) among patients with ESRD remains incompletely characterized. This study was undertaken to compare resource utilization, costs, and clinical outcomes among SAB-infected patients with ESRD by hemodialysis access type. Adjusted comparisons of costs and outcomes were based on multivariable linear regression and multivariable logistic regression models, respectively. A total of 143 hospitalized hemodialysis-dependent patients had SAB at Duke University Medical Center between July 1996 and August 2001. A total of 111 (77.6%) patients were hospitalized as a result of suspected bacteremia; 32 (22.4%) were hospitalized for other reasons. Of the 111 patients, 59.5% (n = 66) had catheters as their primary access type, 36% (n = 40) had arteriovenous (AV) grafts, and 4.5% (n = 5) had AV fistulas. Patients with fistulas were excluded from analyses because of small numbers. Patients with catheters were more likely to be white, had shorter dialysis vintage, and had higher Acute Physiology and Chronic Health Evaluation II scores compared with patients with grafts. Unadjusted 12-wk mortality did not significantly differ between patients with catheters compared with patients with grafts (22.7 versus 10.0%; P = 0.098); neither did 12-wk costs differ by access type ($22,944 +/- 18,278 versus $23,969 +/- 13,731, catheter versus graft; P > 0.05). In adjusted analyses, there was no difference in 12-wk mortality (odds ratio 1.63; 95% confidence interval 0.29 to 9.02; catheter versus graft) or 12-wk costs (means ratio 0.84; 95% confidence interval 0.60 to 1.17; catheter versus graft) among SAB-infected patients with ESRD on the basis of hemodialysis access type. Twelve-week mortality and costs that are associated with an episode of SAB are high in hemodialysis patients, regardless of vascular access type. Efforts should focus on the prevention of SAB in this high-risk group.

Design of the Dialysis Access Consortium (DAC) Aggrenox prevention of access stenosis trial

Surgically created arteriovenous (AV) grafts are the most common type of hemodialysis vascular access in the United States, but fail frequently due to the development of venous stenosis. The Dialysis Access Consortium (DAC) Aggrenox Prevention of Access Stenosis Trial tests the hypothesis that Aggrenox (containing dipyridamole and aspirin) can prevent stenosis and prolong survival of arteriovenous grafts. This is a multicenter, randomized, double-blind, placebo-controlled trial that will enroll 1056 subjects over four years with one-half year follow-up. Subjects undergoing placement of a new AV graft for hemodialysis are randomized to treatment with Aggrenox or placebo immediately following access surgery. The primary outcome is primary unassisted patency defined as the time from access placement until thrombosis or an access procedure carried out to maintain or restore patency. The major secondary outcome is cumulative access patency. Monthly access flow monitoring is incorporated in the study design to enhance detection of a hemodynamically significant access stenosis before it leads to thrombosis. This paper describes the key issues in trial design, broadly including: 1) ethical issues surrounding the study of a clinical procedure that, although common, is no longer the clinical intervention of choice; 2) acceptable risk (bleeding) from the primary intervention; 3) inclusion of subjects already receiving a portion of the study intervention; 4) inclusion of subjects with incident rather than prevalent qualifying clinical conditions; 5) timing of the study intervention to balance safety and efficacy concerns; and 6) the selection of primary and secondary study endpoints. This is the first, large, multicenter trial evaluating a pharmacologic approach to prevent AV graft stenosis and failure, an important and costly problem in this patient population. Numerous design issues were addressed in implementing the trial and these will form a roadmap for future trials in this area.

Relation between Access‐Related Infection and Preinfection Serum Albumin Concentration in Patients on Chronic Hemodialysis

Hemodialysis (HD) access-related infection is a major cause of morbidity and mortality in HD patients. We tested whether hypoalbuminemia is a risk factor for HD access infection and whether mortality of HD catheter infection is affected by removal of the infected catheter. We analyzed the records of 87 patients on chronic HD who were hospitalized for HD access-related infection. We obtained data on age, sex, preinfection serum albumin level, comorbidities, complications, infecting organism, type of infection, mode of management, and mortality. We compared preinfection serum albumin levels in 79 patients with HD access infection with the serum albumin levels of 198 control patients on chronic HD without HD access infection admitted to the hospital during the same time for other reasons. In the HD catheter infection subgroup, we compared mortalities between patients treated with catheter removal plus antibiotics as the primary mode of management and those treated initially with antibiotics alone. Preadmission serum albumin level was lower in the HD access infection group (2.4 +/- 0.6 g/dL) than in the control group (3.2 +/- 0.6 g/dL, P < 0.0001). Logistic regression identified preadmission serum albumin level as a strong independent predictor of HD access infection. In a logistic regression model, with age, sex, HIV status, diabetes, and type of HD vascular access (excluding arterovenous fistula) as the covariates, the odds ratio of HD access infection was 9.8 (95% confidence interval [CI] 4.9-19.7) for a serum albumin level </= 3.0 g/dL (P < 0.0001), 10.4 (95% CI 4.97-21.6) for a serum albumin level </= 2.5 g/dL (P < 0.0001), and 28.0 (95% CI 5.8-135.9) for a serum albumin level </= 2.0 g/dL (P < 0.0001). Case mortality was 25.0% (4/16) in patients with tunneled HD catheter infection initially treated with antibiotics alone and 2.8% (2/71) in those treated with catheter removal plus antibiotics at the time of presentation (P = 0.0096). Hypoalbuminemia is associated with increased risk of HD access infection. Treatment of HD access infection with antibiotics alone is associated with increased risk of death.

Which Vascular Access for Chronic Hemodialysis in Uremic Elderly Patients?

The type of hemodialysis vascular access (fistula, graft, catheter) employed plays an important role in the results of dialysis treatment. Moreover, different complications can affect the vascular access and interfere with the morbidity and mortality of patients. The ideal vascular access is the Cimino Brescia fistula. Graft and catheter methods should be considered as 'second choice' because they present a higher incidence of complications, mainly due to thrombosis and infections. Finally, in elderly patients the vascular bed is frequently damaged and this may make it difficult to create a Cimino Brescia fistula. In a 5-year period, 140 elderly patients (>65 years) and 63 'young' patients (< 65 years) started dialysis treatment in our facility. In the elderly group, a native fistula was created in 88% of cases, whereas in the younger patients the percentage was 94% (p: NS). The grafts were, respectively, 11% in elderly and 6% in young patients. Only in one case, in one elderly patient, was a permanent catheter the first vascular access. We also report survival rate of the first vascular access, the incidence of thrombosis, and the need for creating another type of access. We suggest that a native fistula can be easily created in elderly patients and a 'second choice' access should be limited to a small proportion of patients.

Use of standardized ratios to examine variability in hemodialysis vascular access across facilities

The type of hemodialysis vascular access (catheter, fistula, graft) is an important determinant of patient morbidity and dialysis efficiency. The relative importance of patient versus provider factors in determining type of vascular access is unclear. We sought to develop a quality improvement tool that adjusts for differences in patient characteristics, thereby allowing examination of provider-related variability in types of vascular access used across facilities. We examined 15,339 patients from 216 chronic hemodialysis units in Indiana, Kentucky, Ohio, and Illinois and found that 20% of patients had catheters, 24% had fistulas, and 56% had grafts. Young, male, and white patients were more likely to have fistulas, whereas old, female, and black patients were more likely to have grafts. Diabetics were more likely to have catheters and less likely to have fistulas. New patients were more likely to have catheters and less likely to have grafts. A facility specific standardized catheter ratio (SCR), standardized fistula ratio (SFR), and standardized graft ratio (SGR) were calculated based on the actual number of patients with each type of vascular access divided by the expected number adjusted for patient characteristics. Facility SCRs ranged from 0.00 to 2.87. Of the 216 facilities, 38 (18%) had an SCR significantly less than 1.00, and 32 (15%) had an SCR significantly greater than 1.00. Similar variability was observed in SFRs and SGRs. In conclusion, the type of vascular access varies greatly across facilities. Use of standardized access ratios adjusted for patient characteristics may help providers examine processes of care that contribute to variability in access use. Analogous to the standardized mortality ratio, the SCR, SFR, and SGR should be effective quality improvement tools.

Excess morbidity in patients starting uremia therapy without prior care by a nephrologist

Many inner-city residents with progressive renal disease do not receive specialist care from a nephrologist, and often arrive in the emergency room manifesting life-threatening uremic symptoms requiring emergency rescue dialysis. We examined the relationship between the quality of medical care received during progression to end-stage renal disease, and the clinical condition and morbidity at initiation of renal replacement therapy. During a 5-year period (January 1990 to December 1994), we prospectively studied 139 consecutive inner-city residents with a confirmed diagnosis of chronic renal failure who were starting uremia therapy. At onset of study, subjects were sorted into one of three groups depending on the extent of medical care received during the 3 years immediately preceding initiation of hemodialysis: nephrologist, nonnephrologist (physician), or no medical care. Information obtained from each subject included length of hospital stay during the admission for initiation of dialysis therapy and the type of hemodialysis vascular access used for first dialysis treatment (permanent v temporary). Predialysis blood urea nitrogen concentration, serum creatinine concentration, serum albumin concentration, and serum bicarbonate concentration were measured once immediately before the first dialysis. The 139 study subjects (62 men and 77 women) comprised 116 blacks (83%), 15 Hispanics (11%), and eight whites (6%), and had a mean age of 56 ± 15 years (±SD). Only 59 (43%) subjects received prior specialist nephrologist care, and their mean length of hospital stay (12 ± 23 days) was shorter than that of subjects who received nonnephrologist care (n = 63 [45%]; 25 ± 21 days) or those who received no prior medical care (n = 17 [12%]; 29 ± 23 days) ( P = 0.002). Temporary hemodialysis vascular access was used for the first dialysis in all 17 (100%) of the subjects with no prior medical care, in 56 (89%) of the 63 subjects who received prior care from a nonnephrologist, and in 21 (36%) of the 59 subjects who received prior care from a nephrologist ( P = 0.0001). Subjects who received prior care from a nephrologist had a lower mean serum creatinine concentration at initiation of dialysis (11 ± 4.4 mg/dL) than did either the subjects who received nonnephrologist care (13 ± 5.4 mg/dL) or no medical care (16 ± 5.7 mg/dL) ( P = 0.003). In addition, subjects who received prior care from a nephrologist had less severe metabolic acidosis than the subjects in the other two groups ( P = 0.04). We infer that initiation of uremia therapy is delayed in inner-city residents with progressive renal failure who do not receive specialist nephrologic care, and that as a consequence these patients suffer excess short-term morbidity.