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.

Patients needing hemodialysis are advised to have arteriovenous fistulas rather than catheters because of significantly lower mortality rates. However, disparities in fistula placement raise the possibility that patient factors have a role in this apparent mortality benefit. We derived a cohort of 115,425 patients on incident hemodialysis ≥67 years old from the US Renal Data System with linked Medicare claims to identify the first predialysis vascular access placed. We compared mortality outcomes in patients initiating hemodialysis with a fistula placed first, a catheter after a fistula placed first failed, or a catheter placed first (n=90,517; reference group). Of 21,436 patients with a fistula placed first, 9794 initiated hemodialysis with that fistula, and 8230 initiated dialysis with a catheter after failed fistula placement. The fistula group had the lowest mortality over 58 months (hazard ratio, 0.50; 95% confidence interval, 0.48 to 0.52; P<0.001), with mortality rates at 6, 12, and 24 months after initiation of 9%, 17%, and 31%, respectively, compared with 32%, 46%, and 62%, respectively, in the catheter group. However, the group initiating hemodialysis with a catheter after failed fistula placement also had significantly lower mortality rates than the catheter group had over 58 months (hazard ratio, 0.66; 95% confidence interval, 0.64 to 0.68; P<0.001), with mortality rates of 15%, 25%, and 42% at 6, 12, and 24 months, respectively. Thus, patient factors affecting fistula placement, even when patients are hemodialyzed with a catheter instead, may explain at least two thirds of the mortality benefit observed in patients with a fistula.

The prevalence of vascular disease in each vascular territory also increased with age. After adjustment for sex, race-ethnicity, body mass index, family history of cardiovascular disease, smoking, diabetes, hypertension, hypercholesterolemia, and exercise, the odds of PAD (odds ratio [OR], 2.14; 95% confidence interval [CI], 2.12-2.15), carotid artery stenosis (OR, 1.8; 95% CI, 1.79-1.81), and abdominal aortic aneurysm (OR, 2.33; 95% CI, 2.30-2.36) increased with each decade of life. Comment: Age is a well-known risk factor for atherosclerosis. The data here, if anything, are likely to underestimate the prevalence of vascular disease. Patients who present for screening studies, the so-called worried well, may be more health oriented and live healthier lifestyles than those who do not. After all, patients known to have vascular disease are not really candidates for "screening" studies and, theoretically, would not be included in the database. It seems they would be unlikely to pay for an examination to confirm what they already know.

An arteriovenous fistula (AVF) is the preferential hemodialysis (HD) access. The goal of this study was to identify factors associated with pre-dialysis AVF failure in an elderly HD population. We used United States Renal Data System + Medicare claims data to identify patients ≥ 67 years old who had an AVF as their initial vascular access placed pre-dialysis. Failure of the AVF to be used for initial HD, was used as the outcome. Logistic regression model was used to identify factors associated with AVF failure. The study cohort consisted of 20,360 subjects (76.2 ± 6.02 year old, 58.5% men). Forty-eight percent of patients initiated dialysis using an AVF, while 52% used a catheter or an AVG. The following variables found to be associated with AVF failure when an AVF was created at least 4 months pre-HD initiation: older age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00-1.02), female gender (OR 1.69; 95% CI 1.55-1.83), black race (OR 1.41; 95% CI 1.26-1.58), history of diabetes (OR 1.22; 95% CI 1.06-1.39), cardiac failure (OR 1.26; 95% CI 1.15-1.37), and shorter duration of pre-end-stage renal disease (ESRD) nephrology care (OR for a nephrology care of less than 6 months prior to ESRD of 1.22 compared with a pre-ESRD nephrology follow up of more than 12 months; 95% CI 1.07-1.38). OR for AVF failure for the entire cohort showed similar findings. In an elderly HD population, there is an association of older age, female gender, black race, diabetes, cardiac failure and shorter pre-ESRD nephrology care with predialysis AVF failure.