Should Fistulas Really be First in the Elderly Patient?

Richardson, Albert I.; Leake, Andrew; Schmieder, Gregory C.; Biuckians, Andre; Stokes, Gordon K.; Panneton, Jean M.; Glickman, Marc H.

doi:10.1177/112972980901000311

Cited by 103 publications

(115 citation statements)

References 9 publications

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“…Answer AVF nonmaturation or early failure is associated with older age, female sex, forearm location, and cardiovascular disease (57)(58)(59)(60). In contrast, no clinical factors have been associated with early AVG failure.…”

Section: James C Harms Md (Nephrology Fellow At University Of Alabamentioning

confidence: 99%

A Patient with Recurrent Arteriovenous Graft Thrombosis

Allon¹

2015

Clinical Journal of the American Society of Nephrology

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Arteriovenous grafts (AVGs) are prone to frequent thrombosis that is superimposed on underlying hemodynamically significant stenosis, most commonly at the graft-vein anastomosis. There has been great interest in detecting AVG stenosis in a timely fashion and performing preemptive angioplasty, in the belief that this will prevent AVG thrombosis. Three surveillance methods (static dialysis venous pressure, flow monitoring, and duplex ultrasound) can detect AVG stenosis. Whereas observational studies have reported that surveillance with preemptive angioplasty substantially reduces AVG thrombosis, randomized clinical trials have failed to confirm such a benefit. There is a high frequency of early AVG restenosis after angioplasty caused by aggressive neointimal hyperplasia resulting from vascular injury. Stent grafts prevent AVG restenosis better than balloon angioplasty, but they do not prevent AVG thrombosis. Several pharmacologic interventions to prevent AVG failure have been evaluated in randomized clinical trials. Anticoagulation or aspirin plus clopidogrel do not prevent AVG thrombosis, but increase hemorrhagic events. Treatment of hyperhomocysteinemia does not prevent AVG thrombosis. Dipyridamole plus aspirin modestly decreases AVG stenosis or thrombosis. Fish oil substantially decreases the frequency of AVG stenosis and thrombosis. In patients who have exhausted all options for vascular access in the upper extremities, thigh AVGs are a superior option to tunneled internal jugular vein central vein catheters (CVCs). An immediate-use AVG is a reasonable option in patients with recurrent CVC dysfunction or infection. Tunneled femoral CVCs have much worse survival than internal jugular CVCs.Clin J Am Soc Nephrol 10: 2255-2262, 2015. doi: 10.2215/CJN.00190115 Patient PresentationThe following vignette illustrates the numerous challenges in optimizing arteriovenous graft (AVG) patency in hemodialysis patients. A 28-year-old woman initiated peritoneal dialysis when she developed ESRD because of focal glomerular sclerosis. She was hospitalized with an intracerebral bleed caused by a ruptured aneurysm 1.5 years later. A ventricular-peritoneal shunt was placed to treat hydrocephalus, and she was anticoagulated with warfarin to keep the shunt patent. Because of residual left-sided weakness and inadequate family support, she was no longer able to perform peritoneal dialysis. A tunneled central vein catheter (CVC) was placed in the right internal jugular vein, and she was switched to maintenance hemodialysis. A left forearm arteriovenous fistula (AVF) clotted 2 weeks after its creation. A subsequent looped left upper-arm AVG was successfully cannulated 5 weeks after its creation. It clotted four times during the ensuing 6 months and was treated each time by an interventional radiologist or nephrologist, who performed percutaneous thrombectomy, in conjunction with angioplasty of a venous anastomotic stenosis. The patient resumed hemodialysis with an internal jugular CVC when the AVG failed. A right radiocephalic AV...

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Section: James C Harms Md (Nephrology Fellow At University Of Alabamentioning

confidence: 99%

A Patient with Recurrent Arteriovenous Graft Thrombosis

Allon¹

2015

Clinical Journal of the American Society of Nephrology

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“…Comorbidities, functional status, life expectancy, and social factors should play a major role in the decision-making process. To determine if fistulas should be the preferred option in elderly patients, Richardson et al analyzed outcomes after AVF surgery in 48 elderly patients and reported only eight AVFs being accessed for dialysis, suggesting that, despite K/DOQI guidelines (which do not have recommendations for specific age groups), AVFs may not be the best option in patients over 70 years of age (25). Another study found that the intervention and survival rates were similar among older (Ͼ65 years old) and younger (Ͻ65) dialysis patients after radiocephalic and brachiocephalic AVF.…”

Section: Should Avf Be Chosen For Access In All Elderly Patients?mentioning

confidence: 99%

Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis

Vachharajani

Moossavi

Jordan

et al. 2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Octogenarians frequently require maintenance hemodialysis (HD) for treatment of stage renal disease ESRD. Although the Fistula First Initiative recommends creating an arteriovenous fistula as the preferred dialysis access method, vascular access selection should be based on life expectancy and functional status at treatment initiation. Results Thirty-seven octogenarian patients selected HD and two selected peritoneal dialysis. Among the 37 HD patients, 29 initiated dialysis with a tunneled cuffed catheter, 6 with an arteriovenous fistula, and 2 with an arteriovenous graft. Three patients regained renal function after an average 112 days and one was lost to follow-up. Of the 33 remaining on HD, 8 required nursing home admission and 25 were discharged home after initiating HD. Among these 33, 19 died and 14 remained on HD at the end of study period. Days on dialysis (mean Ϯ SEM) before death in those discharged to a nursing facility versus home were 52.6 Ϯ 14.7 versus 386.1 Ϯ 90.7 (P Ͻ 0.05), respectively.Conclusions Vascular access planning should include assessment of functional status and life expectancy in octogenarian HD patients.

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“…A recent study illustrated in stark details how advanced age might affect clinical judgment regarding choice of vascular access (45). This observational study compared fistula and patient survival in dialysis-dependent patients older or younger than 70 years of age.…”

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confidence: 99%

Dialysis Fistula or Graft

Allon

Lok

2010

Clinical Journal of the American Society of Nephrology

130

121

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The Fistula First Initiative has strongly encouraged nephrologists, vascular access surgeons, and dialysis units in the United States to make valiant efforts to increase fistula use in the hemodialysis population. Unfortunately, the rigid "fistula first" recommendations are not based on solid, current, evidence-based data and may be harmful to some hemodialysis patients by subjecting them to prolonged catheter dependence with its attendant risks of bacteremia and central vein stenosis. Once they are successfully cannulated for dialysis, fistulas last longer than grafts and require fewer interventions to maintain long-term patency for dialysis. However, fistulas have a much higher primary failure rate than grafts, require more interventions to achieve maturation, and entail longer catheter dependence, thereby leading to more catheter-related complications. Given the tradeoffs between fistulas and grafts, there is equipoise about their relative merits in patients with moderate to high risk of fistula nonmaturation. The time is right for definitive, large, multicenter randomized clinical trials to compare fistulas and grafts in various subsets of chronic kidney disease patients. Until the results of such clinical trials are known, the optimal vascular access for a given patients should be determined by the nephrologist and access surgeon by taking into account (1) whether dialysis has been initiated, (2) the patient's life expectancy, (3) whether the patient has had a previous failed vascular access, and (4) the likelihood of fistula nonmaturation. Careful clinical judgment should optimize vascular access outcomes and minimize prolonged catheter dependence among hemodialysis patients.

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Should Fistulas Really be First in the Elderly Patient?

Abstract: This data suggest in the elderly patients, autogenous fistulas may not be the best option for this set of patients.

Cited by 103 publications

References 9 publications

A Patient with Recurrent Arteriovenous Graft Thrombosis

A Patient with Recurrent Arteriovenous Graft Thrombosis

Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis

Dialysis Fistula or Graft

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