Important epidemiological studies and findings often arise from very simple clinical observations. In a letter to Nephrology Dialysis and Transplantation in 1997, de Almeida and colleagues1 noted reduced survival in hemodialysis patients who required more than 1 vascular access over a period of 2.5 years of follow up. This short letter was (unusually) accompanied by an editorial comment by Woods and Port broadening the hypothesis and suggesting that commencing hemodialysis without permanent vascular access could be associated with increased patient morbidity and possibly mortality via an increased risk of infection and the delivery of a lower dialysis dose.2 They suggested that the effect of vascular access a??on morbidity and mortality among incident haemodialysis patients should be tested in large prospective epidemiological studies. Ideally such studies should be based on a random national sample so that they are nationally representative rather than simply reflecting the practice of single centres.a??