← the access Reviewed as of 15 July 2026
THE ACCESS · WHAT HAPPENS TO A PATIENT?

The Crossroads

Planned start vs. crashing in—the two ways a person enters dialysis, and where they converge.

TEXT ALTERNATIVE ↓
THE PROLOGUE THE CROSSROADS THE EXITS THE ~90-DAY BOUNDARY · FORM CMS-2728 FILED · MEDICARE ENTITLEMENT BEGINS · THE FEDERAL MAP OPENS screening / PCP referral symptomatic ED presentation rapid progression / lost to follow-up staged eGFR decline, access placed in advance renal function returns nephrology follow-up (LOOP) preemptive transplant — bypasses dialysis entirely no recovery by ~90 days — chronic ESRD begins home training care partner burnout / clinical instability peritonitis, membrane failure, catheter loss later PD conversion waitlist / living donor patient decision graft failure — the route returns UNDIAGNOSED CKD KNOWN CKD 1 NEPHROLOGY MONITORING CRASH START 2 HOSPITAL ACUTE DIALYSIS AKI — FUNCTION RECOVERED PLANNED START OUTPATIENT TRANSITION ESRD — MODALITY SELECTION 3 IDT ASSESSMENT + PATIENT PREFERENCE IN-CENTER HD 3X/WEEK CADENCE HOME HD 5–7X/WK SHORT DAILY NOCTURNAL 3–7 NIGHTS/WK PD — PERITONEAL CAPD CCPD CONSERVATIVE CARE MEDICAL MGMT, NO DIALYSIS WITHDRAWAL HOSPICE / PALLIATIVE DEATH TRANSPLANT FUNCTIONING GRAFT
WIDE DRAWING · SCROLL SIDEWAYS TO READ IT ALL · THE FULL CONTENT IS ALSO IN WORDS BELOW
A state—where a person is
A transition—how they move between states
The followed route—the one reading this plate traces
The 90-day boundary—the acute-to-chronic line. Three clocks meet near it: the 90-day AKI-to-ESRD convention, the CMS-2728 filed within 45 days of the first chronic outpatient treatment, and the Medicare waiting period, about three months (waivable via home training)
A crossing corridor—where a route crosses that boundary
Reviewed as of 15 July 2026 Changelog

The drawing in words

  1. Undiagnosed CKD—kidney failure not yet recognized or referred.
  2. Known CKD—followed under nephrology monitoring.
  3. Crash start—symptomatic presentation to the emergency department, then hospital acute dialysis. Unrecognized CKD and lost-to-follow-up CKD both arrive here. [1 · VIA SECONDARY SOURCE]
  4. Planned start—a staged eGFR decline with vascular access placed in advance, transitioning to outpatient care. [2]
  5. AKI, function recovered—some who crash regain renal function and return to nephrology follow-up. This is a loop, not an exit. [1 · VIA SECONDARY SOURCE]
  6. ESRD, modality selection—where both routes converge. An interdisciplinary team assessment plus the patient’s own preference. [3]
  7. In-center haemodialysis—a three-times-weekly cadence. [2]
  8. Home haemodialysis—five to seven times a week short daily, or nocturnal three to seven nights a week. [4]
  9. Peritoneal dialysis.
  10. Conservative care—medical management without dialysis.
  11. Transplant—a functioning graft.
  12. Withdrawal—hospice or palliative care.
  13. Death.

BRACKETED NUMBERS TRACE EACH LINE TO THE SOURCE LIST BELOW · EVERY SOURCE IS HELD IN THE REFERENCES LEDGER WITH ITS LOCATOR, ITS LAST-CHECKED DATE, AND HOW IT WAS VERIFIED