The Dialysis Outcome and Quality Initiative (DOQI) recommendations

National surveys have demonstrated that the US End Stage Renal Disease (ESRD) program has witnessed an increasing number of patients each and every year with a corresponding increase in cost. However, when compared to the data from the ESRD program of other countries, we find that these US patients have a low rate of autogenous arteriovenous access (AVA) placement and increased use of nonautogenous (or prosthetic) AVA. Some of the impetus for this can be attributed to (1) the lack of adequate or easily identifiable superficial veins in patients starting on hemodialysis with a history of multiple venipuncture or obesity, (2) earlier access rates of nonautogenous AVA as compared to autogenous AVA, (3) the relative ease of placement of nonautogenous AVA, and (4) a prior payment differential in favor of nonautogenous AVA placement that has since been abolished. However, by virtue of the increased number of procedures required to maintain nonautogenous AVA patency when compared to that of autogenous AVA patency, hemodialysis access failure has become the most frequent cause of hospitalization among ESRD patients. To further investigate this issue, the National Kidney Foundation Dialysis Outcome and Quality Initiative (DOQI) organized multidisciplinary work groups who reviewed 3325 articles concerning various issues of ESRD over a 2-year period. They suggested that autogenous AVA have the best longer-term patency rates and require the fewest interventions as compared to other access types. In order to improve overall patency rates and help contain angioaccess costs, these DOQI recommendations were published in 1997 and updated in 2000. While there is evidence that the guidelines are slowly being adopted, there remains much room for improvement in their implementation.