Creation of arteriovenous fistulae for hemodialysis in octogenarians

Abstract

Elderly patients, defined as octogenarians and nonagenarians, are an increasing population entering renal replacement therapy. Advanced age appears as an exclusive factor negatively influencing dialysis practice. Elderly patients are referred late for the initiation of hemodialysis and more likely are offered catheters rather than arteriovenous fistulae (AVF), which increase mortality and negatively affect quality of life. We present our approach to the creation of vascular access for hemodialysis in this demanding population. In 2006-2012, 39 patients aged 85.9 ± 2.05 with end-stage renal disease, mainly resulting from ischemic nephropathy, were admitted to the Department of Nephrology to establish permanent vascular access for hemodialysis: preferably AVF. Temporary dialysis catheters were implanted in uremic emergency to bridge the time to fistula creation/maturation. AVF was attempted in 87.2% of the patients. Primary AVF function was achieved in 54% of the patients. Cumulative proportional survival of AVF at months 12 and 24 was 81.5%. Ninety-four percent of AVF were localized on the forearm: 74% in the distal and 20% in the proximal part. Mean duration of hemodialysis therapy was 20.80 ± 19.45 months. The mean time of AVF use was 15.9 ± 20.2 months. Until present, 38% have been dialyzed using AVF for 31.0 ± 18.8 months. Five patients died with functioning fistula. Eight patients initiated hemodialysis therapy with fistula. During further observation, the use of AVF increased to 62%. Elderly patients should not be denied creation of AVF as a rule. The outcome of AVF benefits more from acknowledging individual vascular conditions rather than age of the patient.

Hemodialysis in Patients Over 80 Years

“…According to our data patients over 80 years tend to have even slightly less shunt complications than younger patients. Neither did other authors find differences in the elderly [21,22], and especially in patients aged over 80 years [23,24]. Nadeau-Fredette et al reported a higher rate of primary AV-fistula failure in patients over 80 years.…”

Vascular access placement and mortality in elderly incident hemodialysis patients

“…These observations may potentially be explained by the poorer long-term patency and higher risk of complications of AVGs versus AVFs, including thrombosis and infection, leading to a greater number of secondary interventions that may carry potential risk in elderly hemodialysis patients [45,46]. Given that age has not been found to be a potent determinant of AVF patency across multiple studies [47][48][49][50], it may be inferred from our data that AVF should remain as the preferred vascular access type in this population. However, among patients in whom there may be a delay in placement of an AVF from a CVC due to poor maturation or primary access failure, given the high mortality risk observed with a longer duration of CVC use, AVGs may need to be considered as a viable option.…”

Comorbidities, Hospitalization, and Living Status of Dialysis Patients Over 80 Years

“…But this assumption lacks evidence. Other authors did not find differences in the elderly [17,18] , and especially not in patients aged over 80 years [19,20] . Nadeau-Fredette et al [21] reported a higher rate of primary AV-fistula failure in patients over 80 years.…”