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Glenn M. Chertow, MD, MPH
Brigham and Women's Hospital Boston, Mass

JAMA. 1997;277(6):456-457.

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In Reply.

—Dr Qureshi rightly points out that a tunneled catheter may be an optimal "bridge" to an AVF, even in the case of late referral or urgent initiation of dialysis. I agree that a trend toward use of fistulas rather than grafts might have been expected over time, in contrast to what was observed, had this catheter-to-fistula strategy been commonly used.

The results of Dr Tokars and Ms Miller highlight 2 key points: prevalence of graft use over time exceeds its "incidence" at 30 days, and the marked degree of regional variation observed by Hirth et al¹ is attenuated over time. These findings indicate that grafts are even more likely to be used as secondary accesses after failure of a primary graft or fistula.

Drs Tesi and O'Donovan describe an alternative "philosophy," which I strongly support, in which creation of an AVF is attempted in all patients, even those with . . . [Full Text PDF of this Article]

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