Arterio-Venous Fistula: Is it Critical for Prolonged Survival in the over 80's Starting Haemodialysis?

Abstract

BackgroundDialysis in elderly patients (>80-years-old) carries a poor prognosis, but little is known about the most effective vascular access method in this age group. An arteriovenous fistula (AVF) is both time-consuming and initially expensive, requiring surgical insertion. A central venous catheter (CVC) is initially a cheaper alternative, but carries a higher risk of infection. We examined whether vascular access affected 1-year and 2-year mortality in elderly patients commencing haemodialysis.MethodsInitial vascular access, demographic and survival data for elective haemodialysis patients >80-years was collated using regional databases. A cohort of conservatively managed patients was included for comparison. A log-rank test was used to compare survival between groups and a chi-square test was used to compare 1-year and 2-year survival.Results167 patients (61% male) were included: CVC (101), AVF (25) and conservative management (41). Mean age (median) of starting haemodialysis (eGFR ≤10mL/min/1.73m2): CVC; 83.4 (2.3) and AVF; 82.3 (1.8). Mean age of conservatively managed patients reaching an eGFR ≤10mL/min/1.73m2 was 85.8 (3.6). Mean (median) survival on dialysis was 2.2 (1.8) years for AVF patients, 2.1 (1.2) for CVC patients, and 1.5 (0.9) for conservatively managed patients (p = 0.107, controlling for age/sex p = 0.519).1-year and 2-year mortality: AVF (28%/52%); CVC (49%/57%), and conservative management (54%/68%). There was no significant difference between the groups at 1-year (p = 0.108) or 2-years (p = 0.355).ConclusionThese results suggest that there is no significant survival benefit over a 2-year period when comparing vascular access methods. In comparison to conservative management, survival benefit was marginal. The decision of whether and how (choice of their vascular access method) to dialysis the over 80s is multifaceted and requires a tailored, multidisciplinary approach.

Planning and evaluation for vascular access in the elderly

“…A benefit of permanent vascular access over CVC in the older population may exist, though the extent and duration of this benefit is unclear. In hemodialysis patients over the age of 80, there was a trend toward survival advantage at 1 year for AVF (28% vs 49%) as compared to CVC; however, by 2 years the benefit was negligible (52% vs 57%) . The trend toward survival advantage at 1 year may be related to higher infection rates in the CVC group, which is highest in the first 6 months of use .…”

“…Further studies have supported a worse primary access patency at 12 months in patients over 70 years old, 36% vs 67% . This is likely related to atherosclerosis, diabetes, hypertension, and decreased vascular compliance …”

“…Primary failure rates are higher in older patients, specifically in those over the age of 80, as compared to patients in their 50‐60 (40% vs 16%) . Maturation failure rates in patients over the age of 65 ranges from 13% to 70%, higher than a younger population . Further studies have supported a worse primary access patency at 12 months in patients over 70 years old, 36% vs 67% .…”

“…7 Alternative outcomes which may be important to patient centered care include quality of life factors such as swelling from the AVF, requirement of multiple procedures to promote maturation, or need for repeated access placement, extension of hemodialysis treatment time due to prolonged bleeding, the impact on the patient of repeated cannulations of AV access, and pain, bruising and bleeding that may occur. 8,9 These considerations suggest that the decision surrounding access placement should be individualized.…”

Arteriovenous fistula for dialysis — what do we know today?

“…However, in patients over the age of 80, individual patient's preferences and concomitant diseases should be considered. Nevertheless, 93.5% of the population over the age of 75 are suitable for AV fistula creation [19,20].…”