Important issues covered in this multidisciplinary clinic include CKD complications and cardiovascular risk, informing patients and their families, consideration of living transplantation, exploration of psychosocial issues that may impinge on ESKD care, patient transport, choice and preservation of dialysis access sites and vaccination. Patients are referred early to surgeons to assess dialysis access. Clinical and even Doppler examination

is used to identify and mark for preservation of future sites of vascular access. The success of such pre-dialysis programs can be assessed by the percentage of patients that attend the program, that commence dialysis electively, that have Proteasome structure an arteriovenous (AV) fistula as their first haemodialysis access, that commence PD after a 4 week rest of the catheter and – most importantly

– long-term patient outcomes. Similar pre-dialysis educational programs now exist in most countries, and are adapted to suit local needs. For example, in Hong Kong where such programs are run in all dialysis units, there is a major focus on the advantage of PD, consistent with its policy of PD-first. In some Hong Kong centres professionally-produced videos, involving staff and established patients, are an important tool in pre-dialysis education. One of the main determinants of optimal initiation of dialysis is the time of referral of the patient to a nephrologist or renal unit. Australia BMN 673 concentration and New Zealand have comprehensive data on all dialysis and transplant patients, in the Australian and New Zealand Society Of Nephrology (ANZDATA) registry. According to ANZDATA,15 23–28% of patients annually during the 5 year period from 2003 were referred late (defined Tobramycin as referral within 3 months of commencing dialysis). There has been no improvement in the rates of

late referral and the rates do not differ across all age groups (excluding the very elderly). Amongst Aboriginal and Torres Strait Islanders and Pacific Islanders late referral in Australia is 33–37%. This is important because patient 1, 2 and 3 year survival is worse amongst those referred late. The Dialysis Outcomes and Practice Patterns Study (DOPPS) has collected relevant data.16 In countries surveyed (including several from Asia), between 70% and 90% of patients had a nephrology visit within a month of commencing haemodialysis. Survival of patients with a pre-dialysis visit was significantly better than for those who had no visit prior to dialysis, and survival correlated with the number of visits, being greatest in those with five or more in the year prior to commencement. Other guidelines have been developed in Australia to educate general practitioners about the appropriate time to refer a patient to a nephrologist.