Association between initial type of hemodialysis access used in the elderly and mortality

DeSilva, Ranil; Sandhu, Gurprataap S.; Garg, Jalaj; Goldfarb–Rumyantzev, Alexander S.

doi:10.1111/j.1542-4758.2011.00661.x

Cited by 52 publications

(71 citation statements)

References 23 publications

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“…Participants' baseline characteristics are shown in Table 1 and comparable with those characteristics reported in the US Renal Data System (USRDS) (8). The mean (SD) age of the cohort was 59.9 (15.7) years, with dialysis vintage of 1.7 (3.2) years.…”

Section: Patients Characteristicssupporting

confidence: 48%

“…In a cohort of 33 dialysis-dependent octogenarians, of which 78% of patients were using TCVCs, 19 deaths occurred within 18 months of study, but 0 deaths were related to CRBSIs (10). Furthermore, DeSilva et al (8) showed that dialysis mortality rates were similar between AVG and TCVC as first vascular access in patients 81-90 years old with prior malignancy or PVD; additionally, DeSilva et al (8) showed similar mortality rates between AVF, AVG, and TCVC in patients.90 years old with prior malignancy, PVD, or diabetes. A randomized trial of AVF versus AVG versus watchful waiting with TCVC placement in elderly patients with advanced CKD would address whether dialysis catheters impact survival.…”

Section: Discussionmentioning

confidence: 98%

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Risk of Catheter-Related Bloodstream Infection in Elderly Patients on Hemodialysis

Murea¹,

James²,

Russell³

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives Elderly patients require tunneled central vein dialysis catheters more often than younger patients. Little is known about the risk of catheter-related bloodstream infection in this population. Results In total, 374 nonelderly and 90 elderly patients with mean (SD) ages of 54.8 (12.3) and 81.3 (4.9) years and dialysis vintages of 1.8 (3.3) and 1.5 (2.9) years (P=0.47), respectively, were identified. Mean at-risk catheter-days were 272 (243) in nonelderly and 318 (240) in elderly patients. Between age groups, there were no significant differences in initial catheter site, type of catheter lock solution, or microbiology results. A total of 208 catheterrelated bloodstream infection events occurred (190 events in nonelderly and 18 events in elderly patients), with a catheter-related bloodstream infection incidence per 1000 catheter-days of 1.97 (4.6) in nonelderly and 0.55 (1.6) in elderly patients (P,0.001). Relative to nonelderly patients, the hazard ratio for catheter-related bloodstream infection in the elderly was 0.33 (95% confidence interval, 0.20 to 0.55; P,0.001) after multivariate analysis.Conclusion Elderly patients on hemodialysis using tunneled central vein dialysis catheters are at lower risk of catheter-related bloodstream infection than their younger counterparts. For some elderly patients, tunneled central vein dialysis catheters may represent a suitable dialysis access option in the setting of nonmaturing arteriovenous fistulae or poorly functioning synthetic grafts.

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Section: Patients Characteristicssupporting

confidence: 48%

Section: Discussionmentioning

confidence: 98%

Risk of Catheter-Related Bloodstream Infection in Elderly Patients on Hemodialysis

Murea¹,

James²,

Russell³

et al. 2014

Clinical Journal of the American Society of Nephrology

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“…Similar reports have been published by Swindlehurst et al [101] , according to which the creation of permanent HD access in the elderly with AVF is not only possible but also proved to have a short hospital stay, high patency rates and an acceptable rate of further intervention. Desilva et al [102] state that, while specific subgroups in the HD population exist where use of fistulas and grafts at time of dialysis initiation is not of proven statistical benefit to survival, elderly HD patients with comorbidities still appear to benefit from the use of fistulas and grafts. Therefore, it is clear that a primary fistula strategy in incident elderly ESRD is feasible and does not result in inferior outcomes.…”

Section: Mortality and Morbidity Of Vascular Accessmentioning

confidence: 99%

Vascular access today

Pantelias

Grapsa²

2012

WJN

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The number of patients with chronic kidney disease requiring renal replacement therapy has increased worldwide. The most common replacement therapy is hemodialysis (HD). Vascular access (VA) has a key role for successful treatment. Despite the advances that have taken place in the field of the HD procedure, few things have changed with regards to VA in recent years. Arteriovenous fistula (AVF), polytetrafluoroethylene graft and the cuffed double lumen silicone catheter are the most common used for VA. In the long term, a number of complications may present and more than one VA is needed during the HD life. The most common complications for all of VA types are thrombosis, bleeding and infection, the most common cause of morbidity in these patients. It has been estimated that VA dysfunction is responsible for 20% of all hospitalizations. The annual cost of placing and looking after dialysis VA in the United States exceeds 1 billion dollars per year. A good functional access is also vital in order to deliver adequate HD therapy. It seems that the native AVF that Brescia and Cimino described in 1966 still remains the first choice for VA. The native forearm AVFs have the longest survival and require the fewest interventions. For this reason, the forearm AVF is the first choice, followed by the upper-arm AVF, the arteriovenous graft and the cuffed central venous catheter is the final choice. In conclusion, VA remains the most important issue for patients on HD and despite the technical improvements, a number of problems and complications have to be resolved.

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“…Therefore, although the incident use of AVGs in the elderly decreased from 28.2% in the mid-1990s to 4.2% recently, the incident catheter use has increased from 56.8% to 82.3%. 5,6,10 The incident HD population is aging, with an annual increase of 8%-16% in those patients .75 years old. With this increase, it is important to define factors associated with outcomes in the elderly population and particularly, octogenarians.…”

mentioning

confidence: 99%

“…4 For the elderly, past and recent large cohort studies have shown that patients with arteriovenous fistulas (AVFs) have better survival compared with patients with catheters, with the next best vascular access being arteriovenous grafts (AVGs). 5,6 These outcomes were based on the vascular access first used for dialysis and not the access first placed, but the latter may better reflect the actual effect of the fistula first initiative on nephrology practice.…”

mentioning

confidence: 99%

Fistula First Is Not Always the Best Strategy for the Elderly

DeSilva

Patibandla

Vin

et al. 2013

Journal of the American Society of Nephrology

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154

115

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Whether placing a fistula first is the superior predialysis approach among octogenarians is unknown. We analyzed data from a cohort of 115,425 incident hemodialysis patients $67 years old derived from the US Renal Data System with linked Medicare claims, which allowed us to identify the first predialysis vascular access placed rather than the first access used. We used proportional hazard models to evaluate all-cause mortality outcomes based on first vascular access placed, considering the fistula group as the reference. In the study population, 21,436 patients had fistulas as the first predialysis access placed, 3472 had grafts, and 90,517 had catheters. Those patients with a catheter as the first predialysis access placed had significantly inferior survival compared with those patients with a fistula (HR=1.77; 95% CI=1.73 to 1.81; P,0.001). However, we did not detect a significant mortality difference between those patients with a graft as the first access placed and those patients with a fistula (HR=1.05; 95% CI=1.00 to 1.11; P=0.06). Analyzing mortality stratified by age groups, grafts as the first predialysis access placed had inferior mortality outcomes compared with fistulas for the 67 to #79-years age group (HR=1.10; 95% CI=1.02 to 1.17; P=0.007), but differences between these groups were not statistically significant for the 80 to #89-and the .90-years age groups. In conclusion, fistula first does not seem to be clearly superior to graft placement first in the elderly, because each strategy associates with similar mortality outcomes in octogenarians and nonagenarians.

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Association between initial type of hemodialysis access used in the elderly and mortality

Cited by 52 publications

References 23 publications

Risk of Catheter-Related Bloodstream Infection in Elderly Patients on Hemodialysis

Risk of Catheter-Related Bloodstream Infection in Elderly Patients on Hemodialysis

Vascular access today

Fistula First Is Not Always the Best Strategy for the Elderly

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