LAUSR

AVF placement, was also associated with the mortality benefit. This finding adds to the recent studies by Quinn et al. [2] and Brown et al. [3] that propose a more nuanced view of the optimal care of patients with chronic kidney disease (CKD) stages 4 and 5. In these studies, patients who underwent an ultimately non-successful AVF placement and initiated dialysis with a hemodialysis catheter had improved mortality compared to those who had initiated dialysis with a catheter and had yet not undergone AVF construction. These findings imply that it is not solely the vascular access itself but also the prosecution of pre-ESRD nephrology care for greater than 12 months that provides an equal portion of the survival advantage following the onset of dialysis. The results of Quinn et al. [2] and Brown et al. [3] augment and complement the growing body of literature that demonstrates the benefits of pre-ESRD nephrology care, particularly in the form of an interdisciplinary CKD clinic. Pre-ESRD nephrology education using an interdisciplinary approach results in more patients beginning dialysis at home, and also leads to a greater percentage of patients with a permanent access when in-center hemodialysis is chosen [4] . The interdisciplinary CKD clinic In this issue of the American Journal of Nephrology , Nee et al. [1] demonstrate that patients who initiated dialysis while receiving care through the Military Health System (MHS) had a superior 1-year survival than those who initiated dialysis outside of the MHS. MHS patients were also more likely to receive pre-end-stage renal disease (ESRD) nephrology care (defined as nephrology care, dietary education, and use of erythropoiesis-stimulating agents [ESAs]) and have a functioning arteriovenous fistula (AVF) at the commencement of dialysis compared to non-MHS patients. AVF placement and preESRD nephrology care provided much of the survival advantage. Pre-ESRD nephrology care of greater than 12 months’ duration had a survival impact comparable to that of a functioning AVF. The authors concluded that pre-ESRD nephrology care and vascular access placement led to less mortality. The results derived from these data in some ways are not surprising. Dialysis initiation with an AVF has long been associated with decreased mortality for incident hemodialysis patients, and access placement has been a defining goal of pre-ESRD nephrology care. The interesting twist is that pre-ESRD nephrology care itself, not just the Published online: May 13, 2017 Nephrology American Journal of