Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis

Abstract

SummaryBackground and objectives Octogenarians frequently require maintenance hemodialysis (HD) for treatment of stage renal disease ESRD. Although the Fistula First Initiative recommends creating an arteriovenous fistula as the preferred dialysis access method, vascular access selection should be based on life expectancy and functional status at treatment initiation. Results Thirty-seven octogenarian patients selected HD and two selected peritoneal dialysis. Among the 37 HD patients, 29 initiated dialysis with a tunneled cuffed catheter, 6 with an arteriovenous fistula, and 2 with an arteriovenous graft. Three patients regained renal function after an average 112 days and one was lost to follow-up. Of the 33 remaining on HD, 8 required nursing home admission and 25 were discharged home after initiating HD. Among these 33, 19 died and 14 remained on HD at the end of study period. Days on dialysis (mean Ϯ SEM) before death in those discharged to a nursing facility versus home were 52.6 Ϯ 14.7 versus 386.1 Ϯ 90.7 (P Ͻ 0.05), respectively.Conclusions Vascular access planning should include assessment of functional status and life expectancy in octogenarian HD patients.

New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients?

“…The complexities of AV access planning are highlighted in a study of octogenarians, which showed that, of those who had preoperative vein mapping during the predialysis period, all had AVFs created (16); however, 32% died before needing to start dialysis (16). Furthermore, within the cohort, 57.5% of patients died within 18 months of starting dialysis (16).…”

“…Furthermore, within the cohort, 57.5% of patients died within 18 months of starting dialysis (16). Of these patients who died, 55.5% died within 6 months of starting dialysis: 70% of them had AVFs created, but none of the AVFs matured to allow for cannulation before the patients died (16).…”

A Preponderance of Evidence Is Sufficient

“…Likely, for many patients, palliative nondialysis care would have been of more comfort to the patient and the family. Sicker and older patients are more likely to require indwelling vascular access catheters, perhaps even appropriately so, but at a cost of enhanced infection and sepsis (5). Indeed, the serum albumin concentration was lower in those who died earlier, confirming, in part, this observation of lesser health and visceral malnutrition and/or chronic inflammation.…”

Informing Our Elders About Dialysis

“…Older patients lose renal function at slower rates than their younger counterparts, have a low incidence of progression to ESRD, and have shorter survival (6,(24)(25)(26)(27)(28)(29). Many older CKD patients die long before reaching dialysis because of significant cardiovascular mortality with higher stages of CKD (6,(24)(25)(26)(27)(28)(29).…”

“…Many older CKD patients die long before reaching dialysis because of significant cardiovascular mortality with higher stages of CKD (6,(24)(25)(26)(27)(28)(29). Older adults were 13 times more likely to die of any cause than progress to ESRD and six times more likely to die of cardiovascular disease than develop ESRD (27).…”