Effect of Age on the Association of Vascular Access Type with Mortality in a Cohort of Incident End-Stage Renal Disease Patients

Abstract

Background/Aims: All hemodialysis (HD) patients are generally recommended to create a fistula first; but to create a mature arteriovenous fistula (AVF) can be challenging in elderly individuals. It is unclear if elderly incident HD patients derive a survival benefit from an AVF over an arteriovenous graft (AVG) or a tunneled central venous catheter (TDC). Methods: We examined the association of vascular access type (AVF, AVG, and TDC with and without a maturing AVF/AVG at dialysis transition) at HD initiation with all-cause, cardiovascular (CV), and infection-related mortality in 46,786 US veterans using Cox models with adjustment for confounders. Effect modification by age was examined by examining associations in pre-specified age subgroups (<60, 60-<70, 70-<80, and ≥80 years old), and by including interaction terms. Results: Patients numbering 8,940 (19%) started HD with an AVF, 1,090 (3%) with an AVG, 8,262 (18%) with a TDC and a maturing AVF/AVG and 28,494 (61%) with a TDC without a maturing AVF/AVG. A total of 13,303 all-cause, 4,392 CV, and 1,058 infection-related deaths were observed in the first year after HD transition. Compared to patients with AVF, those with AVG and TDC with and without maturing AVF/AVG had incrementally higher overall risk of all-cause mortality and CV mortality. Only TDC use was associated with higher infection-associated mortality. These associations were not modified by age. Conclusion: Although most of our patients consisted of male veterans and the results may not be generalized to the general population, the use of TDCs is associated with poor outcomes even in the most elderly incident HD patients.

Vascular access‐related mortality in hemodialysis patients during and after hospitalization

“…In addition, wearing a catheter enhances the risk of mortality more than 12‐fold, even after adjustment for several variables. The choice of a vascular access different from an autologous fistula leads to many complications including infections and dysfunction 19 . The first one contributes to higher rates of hospitalizations and mortality but our study suggests that catheter predicts mortality independently from reason for admission and comorbidities 20 …”

Vascular access placement and mortality in elderly incident hemodialysis patients

“…patients who initiated hemodialysis with a functioning AVF/ AVG may have had better access to or compliance with predialysis nephrology care). It has been suggested that patients' underlying conditions during the predialysis period have a greater impact on outcomes than the effect of access itself [18,42,43], and the survival benefits of AVFs/AVGs over CVCs may be minimal among patients who are at higher risk of AVF/ AVG failure (i.e. older age, female, diabetic) [44].…”

“…While associated with better clinical outcomes in the general hemodialysis population [6][7][8][9], use of arteriovenous fistulas (AVFs) in elderly hemodialysis patients poses unique challenges given their higher rates of inadequate maturation of vascular access and limited life expectancy [10][11][12]. Moreover, there remains wide debate as to whether the Fistula First Breakthrough Initiative should be applied to the elderly hemodialysis population [12][13][14][15], given operational risks, longer maturation times and emerging data indicating the lack of a survival benefit compared with tunneled dialysis catheter [central venous catheter (CVC)] and/or arteriovenous graft (AVG) use in elderly patients [16][17][18].…”

Octogenarians and Nonoctogenarians Have Similar Outcomes after Upper Extremity Hemodialysis Access Creation

“…15,16 The superiority of permanent access has been specifically demonstrated in the elderly. 7,12,17 It has been suggested that AVGs may be favorable in older populations with more comorbidities and shorter life expectancies, due to the extended maturation time of AVFs. 18,19 However, conflicting research findings showed AVFs to have similar or better outcomes as prosthetic AVGs in the elderly.…”

“…Some studies have shown that age has no significant impact on catheters and AV access outcomes, with older patients having comparable outcomes to their younger counterparts. 12,13 Others have concluded that the benefit of AV access for HD decreases with advancing age, as older patients in those studies were found to have lower maturation rates, higher rates of reintervention, and lower patency rates. 5,7e10,14 In addition, there are limited data to guide access creation in octogenarians.…”