Fistulas in Octogenarians: Are They Beneficial?

Comparison between radiocephalic and brachiocephalic arteriovenous fistula in octogenarians: A retrospective single center study

PURPOSE

The number of older patients who need vascular access for end-stage renal disease is rapidly increasing. However, determining the optimal vascular access for older patients is difficult. We aimed to compare the outcomes of radiocephalic (RC) and brachiocephalic (BC) arteriovenous fistula (AVF) in patients aged >80 years.

METHODS

This study included 94 patients undergoing hemodialysis who underwent the procedure for the first time between 2013 and 2019 in Korea University Guro Hospital. The primary outcomes were primary patency (PP) and cumulative patency (CP). The secondary outcome was maturation failure and death with functional vascular access.

RESULTS

Of the 94 patients (mean age, 83.9 ± 2.97 years), 66 (70.2%) and 28 (29.8%) patients belonged to the RC and BC AVF groups, respectively. One-year PP was worse in the RC AVF group than in the BC AVF group (59.6% vs. 87.4%, p = 0.013). However, no significant difference was observed in 1-year CP between the groups (87.4% vs. 91.2%, p = 0.441). The unassisted maturation rate was higher in the BC AVF group than in the RC AVF group (74.2% vs. 96.4%, p = 0.011). During follow-up (649 ± 612 days), only 6 (6.4%) patients required secondary fistula placement. Eighteen patients (19.1%), all of whom had functional AVF, died.

CONCLUSION

BC AVF showed better PP and a smaller number of interventions than RC AVF in octogenarians. Therefore, BC AVF could be a primary choice of vascular access in the octogenarian patient. However, further research is warranted to confirm these findings.

Hemodialysis vascular access in elderly patients: A comprehensive review

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.

Vascular access placement and mortality in elderly incident hemodialysis patients

BACKGROUND

Arteriovenous fistulas (AVFs) are the preferred vascular access type in most hemodialysis patients. However, the optimal vascular access type in octogenarians and older (≥80 years) hemodialysis patients remains widely debated given their limited life expectancy and lower AVF maturation rates.

METHODS

Among incident hemodialysis patients receiving care in a large national dialysis organization during 2007-2011, we examined patterns of vascular access type conversion in 1 year following dialysis initiation in patients <80 versus ≥80 years of age. Among a subcohort of patients ≥80 years of age, we examined the association between vascular access type conversion and mortality using multivariable survival models.

RESULTS

In the overall cohort of 100 804 patients, the prevalence of AVF/arteriovenous graft (AVG) as the primary vascular access type increased during the first year of hemodialysis, but plateaued thereafter. Among 8356 patients ≥80 years of age and treated for >1 year, those with initial AVF/AVG use and placement of AVF from a central venous catheter (CVC) had lower mortality compared with patients with persistent CVC use. When the reference group was changed to patients who had AVF placement from a CVC in the first year of dialysis, those with initial AVF use had similar mortality. A longer duration of CVC use was associated with incrementally worse survival.

CONCLUSIONS

Among incident hemodialysis patients ≥80 years of age, placement of an AVF from a CVC within the first year of dialysis had similar mortality compared with initial AVF use. Our data suggest that initial CVC use with later placement of an AVF may be an acceptable option among elderly hemodialysis patients.

Should a fistula first policy be revisited in elderly haemodialysis patients?

Life-sustaining haemodialysis requires a durable vascular access (VA) to the circulatory system. The ideal permanent VA must provide longevity for use with minimal complication rate and supply sufficient blood flow to deliver the prescribed dialysis dosage. Arteriovenous fistulas (AVFs) have been endorsed by many professional societies as the VA of choice. However, the high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and arterial hypertension in elderly people, usually make VA creation more difficult in the elderly. Many of these patients may have an insufficient vasculature for AVF maturation. Furthermore, many AVFs created prior to the initiation of haemodialysis may never be used due to the competing risk of death before dialysis is required. As such, an arteriovenous graft and, in some cases, a central venous catheter, become a valid alternative form of VA. Consequently, there are multiple decision points that require careful reflection before an AVF is placed in the elderly. The traditional metrics of access patency, failure and infection are now being seen in a broader context that includes procedure burden, quality of life, patient preferences, morbidity, mortality and cost. This article of the European Dialysis (EUDIAL) Working Group of ERA-EDTA critically reviews the current evidence on VA in elderly haemodialysis patients and concludes that a pragmatic patient-centred approach is mandatory, thus considering the possibility that the AVF first approach should not be an absolute.

Selective placement of autogenous arteriovenous fistulae in an over 80-year-old population

INTRODUCTION

With improved life expectancy and quality of life, elderly patients constitute a progressively larger fraction of consumers utilising renal replacement therapy (RRT). Although substantial data exist for younger cohorts, minimal evidence exists for outcomes of arteriovenous fistula (AVF) and central catheters (CVC) placed in those patients over 80 years. We examined outcomes of primary AVF placement in this cohort to ascertain durability and benefits of AVF in the over 80-year-old population.

METHODS

Retrospective analysis was undertaken of all autogenous AVFs and CVCs placed in patients aged over 80 years at Gold Coast University Hospital between March 2010 and February 2016. Prospectively collected demographic data, co-morbidities and operative factors were analysed.

RESULTS

Sixty-five AVF and 12 CVC patients were identified. Mean age at intervention was 83.9 years and 76% of the patients were male. The majority of procedures were autogenous radio-cephalic AVF; median post-operative length of stay was 2 days. Cumulative AVF patient survival at 12 and 24 months was 82% and 72%, respectively. This was significantly better than survival rates of CVC patients, with 12-month survival of 45%. Primary patency at 6, 12 and 24 months was 58%, 39% and 31%. There were 113 follow-up procedures in 41 patients required to maintain patency.

CONCLUSIONS

Although patency rates are inferior and re-intervention rates higher than in younger patients, AVF can be a durable option for RRT in selected elderly patients with improved mortality rates compared with CVC. Age alone should not preclude primary AVF placement.

Arteriovenous Vascular Access Selection and Evaluation

When making decisions regarding vascular access creation, the clinician and vascular access team must evaluate each patient individually with consideration of life expectancy, timelines for dialysis start, risks and benefits of access creation, referral wait times, as well as the risk for access complications. The role of the multidisciplinary team in facilitating access choice is reviewed, as well as the clinical evaluation of the patient.

Temporary Catheters as a Permanent Vascular Access in Very Elderly Hemodialysis Patients: Frequency of Complications and Interventions

The choice of vascular access in very elderly hemodialysis patients can be complex. Data on the frequency of interventions and complications when temporary catheters are used for long periods in this population are lacking. All incident patients ≥80 years old, dialyzed over non-tunneled catheters, were included and the frequency of interventions (re-insertions and wire-exchanges) and complications (catheter-related blood stream infections) were recorded. In 31 patients aged 84 ± 4 years, dialyzed for 1.4 ± 1.1 years, 87 interventions were needed (2.02/patient-year). The median time to first intervention was 5.5 months and the 1-year intervention-free rate was 32%. There were three catheter-related blood stream infections (0.2/1000 access-days), comparing favorably to tunneled catheters. To conclude, temporary catheters are associated with a low rate of complications and an acceptable rate of interventions. Therefore, they could be the optimal vascular access in very elderly patients when the placement of an arterio-venous fistula is not feasible.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

Hemodialysis arteriovenous fistula as first option not necessary in elderly patients

OBJECTIVE

Kidney Disease Outcomes Quality Initiative guidelines recommend arteriovenous fistulas as the preferred access for hemodialysis patients. However, this may not hold across all populations of patients, especially the elderly, given their comorbidities and relatively reduced life expectancy. Therefore, we investigated whether fistulas held benefit over arteriovenous grafts as hemodialysis access in elderly patients.

METHODS

We retrospectively searched a vascular access database to compare the outcomes for 138 fistulas and 44 grafts that were placed in elderly patients (≥75 years old) during a 4-year period at a tertiary medical center.

RESULTS

The primary failure rate was higher for the fistulas compared with the grafts (odds ratio, 2.89; P = .008), and more fistulas required one or more interventions before their successful use compared with grafts (31% vs 10%, respectively; P = .03). In addition, the time to catheter-free dialysis was longer for fistulas than for grafts (P < .001). However, the primary and secondary patency rates were comparable between the fistulas and grafts and between the different access locations. The all-cause mortality rates were also comparable between the fistula and graft groups.

CONCLUSIONS

Despite the Fistula First Initiative recommendations, grafts need not be discounted as a first-line hemodialysis access option in select elderly patients.