Age is just a number: Is frailty being ignored in vascular access planning for dialysis?

Abstract

Current international guidelines advocate fistula creation as first choice for vascular access in haemodialysis patients, however, there have been suggestions that in certain groups of patients, in particular the elderly, a more tailored approach is needed. The prevalence of more senior individuals receiving renal replacement therapy has increased in recent years and therefore including patient age in decision making regarding choice of vascular access for dialysis has gained more relevance. However, it seems that age is being used as a surrogate for overall clinical condition and it can be proposed that frailty may be a better basis to considering when advising and counselling patients with regard to vascular access for dialysis. Frailty is a clinical condition in which the person is in a vulnerable state with reduced functional capacity and has a higher risk of adverse health outcomes when exposed to stress inducing events. Prevalence of frailty increases with age and has been associated with an increased risk of mortality, hospitalisation, disability and falls. Chronic kidney disease is associated with premature ageing and therefore patients with kidney disease are prone to be frailer irrespective of age and the risk increases further with declining kidney function. Limited data exists on the relationship between frailty and vascular access, but it appears that frailty may have an association with poorer outcomes from vascular access. However, further research is warranted. Due to complexity in decision making in dialysis access, frailty assessment could be a key element in providing patient-centred approach in planning and maintaining vascular access for dialysis.

A decade of arteriovenous fistula creations in the ⩾75 years population: Equal opportunity or sub-optimal use of resources

“…Furthermore, assessment of frailty in potential vascular access and HD patients is limited by the lack of validated frailty assessment scores for this population. 34 Studies have found that nephrologists' perceived frailty as a surrogate for formal assessment of HD patients is poor. 35 Until further work is done to validate clinical frailty scores in the HD population and how it affects vascular access planning, 36 patientcentered outcomes such as quality of life could perhaps offer a better alternative.…”

The frailty phenotype in hemodialysis patients and its association with biochemical markers of mineral bone disorder, inflammation and nutrition

“…Despite the multiple studies concentrating on age and vascular access, there has been negligible work on the association of frailty and vascular access. Limited data exists on this relationship, but it appears that frailty may have an association with poorer outcomes from vascular access [12]. Johansen et al [2] assessed frailty in >3000 incident dialysis patients and determined that individuals with a permanent vascular access (like AVF) were less likely to be frail with hazard ratio 0.72 (95% CI 0.51-0.98) and it was independent of the time of nephrology referral.…”

“…Not just that these factors play a big role but also AVF per se, can have impact on the cardiac function which can lead to its weakness and thus accelerate the persistent disease and therefore the frailty phenotype as well [13]. Due to complexity in decision making in dialysis access, frailty assessment could be a key element in providing patient-centered approach in planning and maintaining vascular access for dialysis [12].…”

The challenging surgical vascular access creation

“…Lok et al (78), however, found that patient age does not significantly affect AVF outcomes, the 1-year fistula survival rate was similar between patients ≥65 years (75.1%) and the younger group (79.7%). Furthermore, Kuningas et al (79) argued the use of age as an independent factor in the decision of creating an AVF, justifying that the age alone does not reflect the general state of health and this should be replaced with more accurate measure such as patient frailty.…”