Preferred Strategy for Hemodialysis Access Creation in Elderly Patients

Abstract

The patient described in this vignette appears to be unsuitable for the creation of a forearm AVF because of calcified distal arteries and a small cephalic vein. The risk of non-maturing autologous AVFs is high in elderly patients and this observation might justify the use of early stick grafts. High risk patients may benefit from permanent central vein catheters.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology

“…Delaying AVF placement may in fact be better, in that some authors suggest that elderly patients with CKD should be referred later to reduce the risk of creating an AVF that will never be used [20]. In this regard, the AVG becomes a valid alternative form of VA if no suitable anatomy for AVF creation and slow renal progression are present [21]; in such cases, the use of early stick graft might be suitable, because of the high risk of non-maturing autologous AVF [22], even though the mortality benefit of AVG over CVC may not apply in the oldest-old (>89 years) age-group [8]. Life expectancy as well as quality of life are important aspects for most patients considering dialysis, and recent data suggest that if dialysis is adequately prepared for in advance it is safe to delay starting HD until the development of signs and symptoms of uremia [23].…”

“…The elderly have specific health care requirements, as they are at increased risk of comorbidities that may result in frailty and reduced physical and cognitive function; furthermore, they often face complex psychosocial, financial, and transportation issues [28]. The creation and use of a VA in elderly patients requires the complex integration of patient, biological and surgical factors because the VA type might be a key factor influencing their survival [2, 9, 22, 29]. Data from the ERA-EDTA registry show that the likelihood of being treated with an AVF was 20, 24 and 37 % lower in the three oldest patient age-groups (60–69, 70–79 and >80 years) when compared to patients aged 22–44 years [30].…”

Future research directions to improve fistula maturation and reduce access failure

“…Olsha et al demonstrated that 88% of their patients who were older than 80 years had vasculature suitable for autogenous access construction, with patency and complications similar to those of their younger counterparts, with adequate preoperative planning and postoperative maintenance [29]. However, elderly patients with ESRD frequently have a high prevalence of comorbidities, short life expectancy, and poor reported quality of life that is associated with lack of AVF maturation and diminished primary and cumulative AVF patency [28]; in these patients AVG placement might be more beneficial [27, 28, 30]. …”

Re: ‘Preferred Strategy for Hemodialysis Access Creation in Elderly Patients’

“…1 The recommendation of an early cannulation arteriovenous graft (AVG) as a first access contradicts all published vascular access guidelines and challenges the "one-size-fitsall" approach to vascular access.Most published outcomes of arteriovenous fistulae (AVFs) are poor, with high primary failure and moderate patency rates. 2 Therefore, the concept of an autologous AVF being the best form of vascular access is only valid if we assume all AVFs work well.…”

“…1 The recommendation of an early cannulation arteriovenous graft (AVG) as a first access contradicts all published vascular access guidelines and challenges the "one-size-fitsall" approach to vascular access.…”