Optimal Hemodialysis Vascular Access in the Elderly Patient

Abstract

The optimal vascular access for elderly patients remains a challenge due to the difficulty balancing the benefits and risks in a population with increased comorbidity and decreased survival. Age is commonly associated with failure to mature in fistula and decreased rates of primary and secondary patency in both fistula and grafts. In the elderly, at 1 and 2-years, primary patency rates range from 43% to 74% and 29% to 67%, respectively. Secondary patency rates at 1 and 2-years range from 56% to 82% and 44% to 67% respectively. Cumulative fistula survival is no better than grafts survival when primary failures are included. Several observational studies consistently demonstrate a lower adjusted mortality among those using a fistula compared to a catheter (1–3)(1–3) however catheter use in the elderly is increasing in most countries with the exception of Japan. Both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing the elderly patients with multiple chronic conditions and limited life expectancy or the value that patients place on achieving these outcomes(4)(4). The framework for choice of vascular access presented in this article considers: 1) likelihood of disease progression before death 2) patient life expectancy, 3) risks and benefits by vascular access type and 4) patient preference. Future studies evaluating the timing and type of vascular access with careful assessments of complications, functionality, cost benefit, and patients’ preference will provide relevant information to individualize and optimize care to improve morbidity, mortality, and quality of life in the elderly patient.

Vascular Access for Hemodialysis in Older Adults

“…Interestingly, the odds ratio rose to 11.1 (95% CI, 6.5 to 19.2) when looking at patients homozygous for the PLA2R1 risk allele but either homozygous or heterozygous for the HLA-DQA1 risk allele. Similar findings have been reported in replication studies from Korea 10 and Taiwan 11 ; the lower odds ratio in Asians suggests true differences in effect size between different ethnicities but may also reflect convergence to the mean. Because…”

“…11,12 This may be an especially important consideration in older adults because of their more limited life expectancy and increased risk of failed fistula maturation. 9,10,13 In this issue of JASN, DeSilva and colleagues provide new information relevant to this dialogue. 14 These authors describe survival among patients age 67 years and older who initiated long-term dialysis from 2005 to 2008 as a function of the type of vascular access first placed.…”

“…These findings add to a growing body of work questioning the wisdom of a "fistula first" approach in older adults and arguing for greater flexibility in choice of hemodialysis access. [7][8][9][10]15,16 A limitation of policies intended to optimize vascular access for hemodialysis in this country has been a failure to take into account the complexities and challenges of the illness experience of individual patients with CKD. Strategies focusing on preferred and least preferred forms of vascular access fail to recognize that the relative benefits and harms of each form of access are critically dependent on the characteristics, circumstances, prognosis, preferences, and goals of individual patients.…”

“…Strategies focusing on preferred and least preferred forms of vascular access fail to recognize that the relative benefits and harms of each form of access are critically dependent on the characteristics, circumstances, prognosis, preferences, and goals of individual patients. 9,10,15,16 Because of heterogeneity in life expectancy, health status, health priorities, and illness experiences, no one approach to vascular access-whether "graft first," "fistula first," or "catheter last"-can be expected to meet the needs of all older adults with advanced kidney disease. 7,9 Further, the traditional outcomes examined in studies of vascular access, such as survival, infection, hospitalization, and costs, may not be those that matter the most to individual patients.…”

Catheter Last, Fistula Not-So-First

“…Several recent publications have challenged the desirability of AVFs over AVGs in elderly patients in particular, 12,13 yet there is no case-mix adjustment for age in the QIP measure for AVF prevalence. CMS policy for the ESRD program is driven by its "Triple Aims": (1) better care for the individual through beneficiary-and family-centered care, (2) better health for the ESRD population, and (3) reduced costs of ESRD care through improved care.…”