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.

Stretching the boundaries: suitability of an arteriovenous fistula in elderly patients on hemodialysis-a northern India experience

PURPOSE

Considering various factors, such as multiple co-morbidities, unsuitable vessels for access creation, non-maturation, vascular calcifications, the outcome of arteriovenous fistula (AVF) in the elderly population, may not be similar to the younger people. Our study aims to analyze the outcomes of AVF in elderly patients (> 65 year).

METHODS

It was a prospective observational study. Patients of more than 65 years of age in whom AVF was created from January 2012 to December 2015 were included in the study. These patients were followed up for 4 years. The primary endpoint of our study was to assess primary and secondary patency rates.

RESULTS

A total of 450 AVFs were included in the study. The mean age was 68.5 years. The most common site of AVF was radiocephalic (RCAVF) in 70% (n = 315), brachiocephalic (BCAVF) in 24% (n = 108) and basilic vein transposition (BVT) in 6% (n = 27). At 48 months, the primary patency rate of RCAVF, BCAVF, and BVT was 55%, 61.6%, and 60.4%, respectively. The commonest cause of access failure was thrombosis followed by non-maturation.

CONCLUSION

AVF remains the preferred vascular access for hemodialysis even in the elderly population. Failure to mature and thrombosis continue to be a concern with AVF. Location of the AV access does not seem to impact the long-term patency.

Redo Hemodialysis Access in Elderly Patients has Acceptable Outcomes With Similar Patency of Arteriovenous Fistulas as Compared to Grafts

OBJECTIVES

Selecting optimal hemodialysis access in elderly patients remains challenging, particularly in those requiring new options after failed initial access. We sought to describe the outcomes of redo hemodialysis access in elderly patients.

METHODS

All patients aged ≥65 undergoing hemodialysis access placement from 2014-2019 were retrospectively identified in the electronic medical record. Characteristics and outcomes of those with initial versus redo access were compared. Patency was depicted utilizing Kaplan-Meier methods, with censoring at loss to follow-up or death, and unadjusted Cox regression.

RESULTS

Overall, 211 elderly patients undergoing 257 procedures were included in the study. Of these, 116 (45.1%) were redo access procedures. There were no demographic or comorbidity differences between the two groups with the exception of central venous stenosis which was more common in the redo cohort (27.2% vs. 6.4%, P < 0.001). 91.5% of initial, vs. 60.3% of redo, procedures were arteriovenous fistulas (P < 0.001). Distribution of fistula type differed between the two groups with first time and redo procedures of 25.5% vs. 6.9% radiocephalic, 28.4% vs. 7.8% brachiocephalic, and 35.5% vs. 37.1% brachiobasilic respectively (P < 0.001). At 12 and 24 months, 63.6% and 44.0% of first-time accesses remained patent vs. 51% and 29.0% of redo accesses (HR 1.37, 95% CI 1.05-1.80, P = 0.02). However, there was no difference in primary patency between redo grafts and fistulas (48.7% fistulas vs. 55.0% grafts at 12 months, P = 0.47).

CONCLUSIONS

These results demonstrate acceptable outcomes of redo access in elderly patients. There is no evidence from this study that prosthetic grafts are preferential, suggesting elderly patients with meaningful life expectancy who require redo access should be offered autogenous options when possible.

Comparing the vascular thromboembolic events following arteriovenous fistula in Chinese population with end-stage renal diseases receiving Clopidogrel versus Beraprost sodium therapy: a retrospective cohort study

BACKGROUND

To assess the time to first on-study vascular thromboembolic events (VTEs) of clopidogrel (CL) or beraprost sodium (BPS) in Chinese population with end-stage renal disease (ESRD) treated with arteriovenous fistula (AVF) surgery.

METHODS

From Jan 2009 to May 2015, 346 ESRD cases suffering an AVF surgery and undergoing oral administration of 75 mg CL (initial dose of 300 mg), 1 time/day, for 4 weeks or 40 μg BPS, 3 times/day, for 4 weeks were retrospectively assessed. The primary outcome was time to first on-study VTE.

RESULTS

In total, 222 ESRD cases (CL, n = 112; BPS, n = 110) were assessed, with a median follow-up time of 38.1 months (range, 37-40 months). The mean time to first on-study VTE was 1.2 weeks (0.5-2.3) and 1.8 weeks (1.2-3.8) for CL and BPS, respectively (HR 0.27, 95% CI 0.16-1.45; P = 0.00). An increased incidence of VTEs was found during the 1th-month follow-up, with rates of 14.2 and 5.5% for CL and BPS, respectively (P = 0.03). The difference persisted over time, with rates of 24.1 and 11.8% at final follow-up, respectively (P = 0.02).

CONCLUSION

CL with an increased risk of VTEs tended to have a VTE within the 1st month after cessation compared with BPS.