Factors predicting failure of <scp>AV</scp> “fistula first” policy in the elderly

Hod, Tammy; DeSilva, Ranil; Patibandla, Bhanu K.; Vin, Yael; Brown, Robert S.; Goldfarb–Rumyantzev, Alexander S.

doi:10.1111/hdi.12106

Cited by 57 publications

(58 citation statements)

References 40 publications

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“…Our results concurred with those of previous studies in finding that the parameters old age and female gender were predictors of unnecessary AVF creation [11]. A simulation study also demonstrated that aging increased the risk of unnecessary AVF creation, mainly due to the competing risk of death [14].…”

Section: Discussionsupporting

confidence: 92%

“…In addition, an increasing number of studies have described the adverse effects of early AVF creation among CKD patients, such as high rates of vascular access complication and death before dialysis commencement [8,9,10,11,12,13]. A US study found that among primarily stages 3 and 4 CKD patients (overall, 78%), the AVF failure and mortality rates during the predialysis periods were 63 and 23%, respectively [9].…”

Section: Introductionmentioning

confidence: 99%

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Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients

et al. 2017

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Background: Most guidelines recommend the creation of arteriovenous fistula (AVF) in patients with chronic kidney disease (CKD) stage 4. However, an increasing number of studies suggest that early AVF creation leads to high rates of AVF failure and death before dialysis commencement. Only the Japanese guideline recommends AVF creation at CKD stage 5; however, no data are available regarding access-related outcomes at this stage. Method: This was a multicenter cohort study involving Japanese CKD stage 5 patients who underwent preemptive AVF creation from 2009 to 2013. The primary outcome was unnecessary AVF creation, defined as death before requiring dialysis or AVF failure before dialysis commencement. The secondary outcome was dialysis commencement. The associations with candidate predictors and the outcomes were examined. Results: A total of 303 patients were registered. Four cases of death before dialysis and 13 cases of AVF failure before dialysis commencement were observed. A total of 283 patients who advanced to dialysis were found to have functional AVFs. The cumulative incidences of unnecessary AVF creation and dialysis commencement at 1 year were 4.8 and 89.3%, respectively. Competing risk regression analyses showed that age ≥75 years (subhazard ratio [SHR] 3.12, 95% CI 1.20-8.09) and female gender (SHR 3.31, 95% CI 1.20-9.09) were associated with unnecessary AVF creation. Conclusions: A low incidence of unnecessary AVF creation was revealed among Japanese patients who received AVF at CKD stage 5. These results may help clarify the natural history of unnecessary AVF creation for other countries reformatting their guidelines regarding late vascular access creation.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients

et al. 2017

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“…Other reports have noted that women and black race are independent risk factors for AVF failure. [32][33][34][35][36][37] Given the higher failure rate in women and blacks as opposed to men and whites, it is possible that placing a fistula earlier in these highrisk subgroups conferred a better outcome by enabling the longer time needed for maturation. However, the longer time before HD initiation may necessitate the performance of endovascular or surgical interventions to achieve adequate patency.…”

Section: Discussionmentioning

confidence: 99%

Arteriovenous Fistula Placement in the Elderly

Hod

Patibandla

Vin

et al. 2015

Journal of the American Society of Nephrology

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Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). However, many AVFs fail before starting dialysis. To assess the optimal time for AVF placement in the elderly, we linked data from the US Renal Data System with Medicare claims data to identify 17,511 patients$67 years old on incident HD who started dialysis between January 1, 2005, and December 31, 2008, with an AVF placed as the first predialysis access. AVF success was defined as dialysis initiation using the AVF, with time between AVF placement and dialysis start as our primary variable of interest. The mean age was 76.166.0 years, and 58.3% of subjects were men. Overall, 54.9% of subjects initiated dialysis using an AVF, and 45.1% of subjects used a catheter or graft. The success rate increased as time from AVF creation to HD initiation increased from 1-3 months (odds ratio [OR], 0.49; 95% confidence interval [95% CI], 0.44 to 0.53) to 3-6 months (OR, 0.93; 95% CI, 0.85 to 1.02) to 6-9 months (OR, 0.99; 95% CI, 0.88 to 1.11) but stabilized after that time. Furthermore, the number of interventional access procedures increased over time starting at 1-3 months, with a mean of 0.64 procedures/patient for AVFs created 6-9 months predialysis compared with 0.72 for AVFs created .12 months predialysis (P,0.001). Although limited by the observational nature of this study, our results suggest that placing an AVF.6-9 months predialysis in the elderly may not associate with a better AVF success rate.

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“…When adjusted using a proportional hazards model that treated death as a competing event, black patients were more likely to start dialysis than die compared with white patients (HR, 1.14; 95% CI, 1.02 to 1.27; P=0.02) ( Table 2). The patients with the highest comorbidity scores (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21) were least likely to initiate hemodialysis compared with those with lower scores (0-4 and 5-10) ( Table 1). When adjusted using a proportional hazards model that treated death as a competing event, the comorbidity scores were no longer associated with likelihood of starting dialysis ( Table 2).…”

Section: Patient Outcomes After Predialysis Vascular Access Creationmentioning

confidence: 99%

“…Applying uniform vascular access guidelines to elderly individuals may not be appropriate because of the competing risk of death, 7,10 the high rate of AVFs that fail to mature, 11 and poor vascular access outcomes in the elderly population. 12 Thus, the objective of this study was to use a large representative United States population to identify the proportion of elderly patients with advanced CKD with predialysis AVF or arteriovenous graft (AVG) creation who survive to initiate dialysis, die before dialysis initiation, or survive dialysis free during 2 years of follow-up.…”

mentioning

confidence: 99%

Outcomes of Elderly Patients after Predialysis Vascular Access Creation

Lee

Thamer

Zhang

et al. 2015

Journal of the American Society of Nephrology

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Uniform vascular access guidelines for elderly patients may be inappropriate because of the competing risk of death, high rate of arteriovenous fistula (AVF) maturation failure, and poor vascular access outcomes in this population. However, the outcomes in elderly patients with advanced CKD who receive permanent vascular access before dialysis initiation are unclear. We identified a large nationally representative cohort of 3418 elderly patients (aged $70 years) with CKD undergoing predialysis AVF or arteriovenous graft (AVG) creation from 2004 to 2009, and assessed the frequencies of dialysis initiation, death before dialysis initiation, and dialysis-free survival for 2 years after vascular access creation. In all, 67% of patients with predialysis AVF and 71% of patients with predialysis AVG creation initiated dialysis within 2 years of access placement, but the overall risk of dialysis initiation was modified by patient age and race. Only one half of patients initiated dialysis with a functioning AVF or AVG; 46.8% of AVFs were created ,90 days before dialysis initiation. Catheter dependence at dialysis initiation was more common in patients receiving predialysis AVF than in patients receiving AVG (46.0% versus 28.5%; P,0.001). In conclusion, most elderly patients with advanced CKD who received predialysis vascular access creation initiated dialysis within 2 years. As a consequence of late predialysis placement or maturation failure, almost one half of patients receiving AVFs initiated dialysis with a catheter. Insertion of an AVG closer to dialysis initiation may serve as a "catheter-sparing" approach and allow delay of permanent access placement in selected elderly patients with CKD.

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Factors predicting failure of AV “fistula first” policy in the elderly

Cited by 57 publications

References 40 publications

Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients

Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients

Arteriovenous Fistula Placement in the Elderly

Outcomes of Elderly Patients after Predialysis Vascular Access Creation

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