Bridging the Gap: Addressing Disparities in Predialysis Nephrology Care

Disparities in predialysis nephrology care are reshaping the clinical landscape, demanding our immediate attention to bridge the gap in patient outcomes, particularly in vascular access, consistent with KDOQI/KDIGO guidance on early referral and preemptive AV access planning. This ongoing challenge affects minority groups disproportionately, leading to suboptimal dialysis initiation and demanding innovative solutions and targeted interventions.

As early missed opportunities accumulate, the role of predialysis nephrology is strongly associated with vascular access type at dialysis initiation, recognizing that late presentation, comorbidities, and patient preferences also influence access choice. Minority groups, including Black/African American, Hispanic, and some Native communities, often encounter systemic barriers, resulting in higher incidences of central venous catheter use, consistent with KDOQI/KDIGO guidance to minimize catheter starts and plan AVF/AVG pre-initiation. These disparities cascade, creating broader healthcare challenges, as highlighted by studies showing that inadequate early nephrology referrals contribute to less favorable vascular access outcomes.

Social determinants consistently impair access to both care quality and vascular options. Factors such as socioeconomic status, health literacy, and geographic barriers exacerbate inequities—aligned with CMS ESRD QIP equity efforts and NAM guidance on integrating SDOH into care. This shared pathway of disadvantage underscores the necessity for culturally responsive healthcare, as recent studies call for pragmatic innovations in addressing predialysis care.

From data to practice, evidence suggests early nephrology referral is associated with a higher likelihood of timely arteriovenous fistula (AVF) planning. These associations point toward narrowing risk at dialysis initiation, though outcomes vary by facility resources, geography, and patient circumstances.

Counterpoint: even when referral occurs, structural barriers can persist. For example, surgical availability, transportation constraints, and insurance authorization delays can prolong catheter dependence despite appropriate planning—reinforcing why equity initiatives must extend beyond clinic walls.

Conditional reasoning offers a practical lens: if referral happens months earlier in progressive CKD, then care teams can complete vein mapping, optimize comorbidities, and engage in shared decision-making for AVF/AVG. If these steps are deferred until dialysis is imminent, the likelihood of catheter starts rises, and opportunities for patient education and preference-concordant access narrow.

Patients' experiences reveal the stark reality of inadequate care access. The immediate impacts—often avoidable—stem from systemic failures, demanding reflection and advocacy. Interventions that focus on social determinants are essential and can improve access planning and reduce catheter starts.

Next logical step: translating data into workflows. Multidisciplinary pathways that embed early referral triggers, navigator support, and proactive access scheduling can align practice with equity goals while respecting patient preferences and medical suitability—creating the conditions for safer starts.

Zooming out, facility- and region-level variation reminds us that improvement is context dependent. Resource investment, workforce capacity, and community partnerships determine how quickly systems can shift from reactive catheter starts to anticipatory AVF/AVG planning while honoring informed choice.

Finally, it is crucial to pinpoint the visible gaps in current nephrology practice. These gaps are highlighted as persistent clinical challenges, where the absence of optimal care strategies leaves many vulnerable. Emerging opportunities lie in systemic reform and policy change to meaningfully reduce disparities, with concrete levers such as the CMS ESRD Quality Incentive Program and the ESRD Conditions for Coverage shaping accountability and resources.

Key Takeaways:

• Socioeconomic and systemic barriers shape vascular access opportunities across multiple groups, including Black/African American, Hispanic, and some Native communities.
• Early nephrology referral is associated with a higher likelihood of timely AVF/AVG planning, not a guarantee of optimal placement.
• Integrating social needs into care can reduce catheter starts and improve access planning over time.
• Programmatic efforts grounded in established standards (KDOQI/KDIGO) can help align practice with equity goals.