THE ACCESS — AN ATLAS OF THE U.S. DIALYSIS SYSTEMPLATE V — FIRST STATE — 07|2026

The Crossroads

A DRAWN MAP · WHAT HAPPENS TO A PERSON

The person’s own map: the planned start or the crash start nobody planned, the preemptive transplant that bypasses the chair entirely, the modality crossroads where the education window either happened or didn’t, the switching loops between center and home, and the exits. The framed region at the top is the prologue: everything that happens before the chronic outpatient map begins.

HOW TO READ · BOX = A STATE A PERSON CAN BE IN · ARROW = THE MOVE BETWEEN THEM · HAIRLINE REGION = THE PROLOGUE — BEFORE THE MAP BEGINS · HAIRLINE BOX = MARGIN NOTE
AN ATLAS OF THE U.S. DIALYSIS SYSTEMWIDE GRAMMAR — STATE MACHINEPLATE V
The CrossroadsFIRST STATE · ED. 001 · 07|2026
PROLOGUE — BEFORE THE MAP BEGINSscreening / PCPreferralsymptomatic EDpresentationrapid progression /lost to follow-upstaged eGFR decline,access placed inadvancerenal function returnsnephrology follow-up(LOOP)preemptive transplant(bypasses dialysisentirely)home trainingcare partner burnout /clinical instabilitywaitlist / living donorpatient decisionpatient decisionno recovery at ~90 days(2728 filed, Medicareentitlement)peritonitis, membranefailure, catheter losslater PD conversiongraft failure (LOOP —returns to modalityselection)patient decisionUndiagnosed CKDKnown CKD — NephrologyMonitoringEDUCATION WINDOW(optimal)Modality education,access planning,transplant eval, KDEbenefit (MIPPA)Crash Start — HospitalAcute DialysisPlanned Start —Outpatient TransitionEDUCATION GAPNo modality educationoccurred.Default pathway =in-center HDvia CVC. Highestmortality cohort.AKI — FunctionRecoveredTransplant —Functioning GraftESRD — Modality SelectionIDT assessment +patient preferenceEDUCATION WINDOW (late)In-facility modalityeducation —a patient right, 42 CFR494.70(a)(7);the IDThome-plan-or-rationaleduty sits at 494.90 —but choice architecturealreadyconstrained by starttypeIn-Center HD — 3x/weekcadenceHome HD — 5–7x/wk shortdaily · nocturnal 3–7nights/wkPDCAPD — manual exchangesCCPD — cycler(nocturnal)Conservative Care —medical mgmt, nodialysisDeathWithdrawal fromDialysis —hospice/palliativeESRD Atlas — View 4: Patient Journey (State Machine) v1
MARGIN — RESERVED FOR THE HAND
KEY
A STATE — WHERE A PERSON IS
A TRANSITION — HOW THEY MOVE
THE PROLOGUE — BEFORE THE MAP
MARGIN NOTE
THE ACCESS · 07|2026
ED. 001 · DRAWN MAP SRC: 42 CFR 494.70(a)(7) / 494.90 · KDOQI · CMS-2728/2746
PLATE V · FIRST STATE DRAWN UNDER THE AUTHOR’S DIRECTION · VERIFIED AGAINST THE ATLAS DATASET
AWAITING THE AUTHOR’S PASS PLATE VI