Vascular Access Outcomes in the Elderly Hemodialysis Population: A USRDS Study

Abstract

Arteriovenous fistulae (AVF) are widely regarded as the preferred vascular access in hemodialysis (HD) patients due to their primary patency and patient survival benefits. Recent scholarship has suggested that the elderly population differs significantly from the general population in terms of inflammatory markers. What is more, recent studies have suggested that the elderly HD population is less likely to have an AVF placed as the initial vascular access compared to a younger cohort. The purpose of this study is to investigate the applicability of current vascular access guidelines to the elderly HD population. We hypothesized that the elderly HD population would derive less patency and survival benefit from AVF placement relative to arteriovenous graft (AVG) than the general population is known to derive. We performed a retrospective analysis using the US Renal Data System (USRDS) Wave II dataset to explore significant predictors of referral for intervention or access failure, and patient survival in the elderly US HD population using Cox regression corrected for race, gender, peripheral vascular disease, diabetes mellitus, and nutritional status. Of the 1471 HD patients with AVF or AVG, 764 patients were >65 years. Elderly diabetics had no significant mortality benefit from the use of AVF compared to AVG [odds ratio (OR) 1.34 (95% CI 0.92-1.95), p = 0.123]. Likewise, elderly nondiabetics had no significant mortality benefit from the use of AVF compared to AVG [OR 1.05 (95% CI 0.81-1.36), p = 0.735]. Elderly diabetics had no difference in odds for intervention referral for AVF compared to AVG [OR 1.49 (95% CI 0.76-2.9), p = 0.24]. Elderly nondiabetics had no difference in odds for intervention referral for AVF compared to AVG [OR 1.48 (95% CI 0.95-2.3), p = 0.08]. We conclude that the potential benefits derived from AVFs compared with AVGs and central venous catheters (CVC) may not apply universally. The recommendations of vascular access choice stipulated by national guidelines may need to be modified for elderly patients.

Early Failure of Dialysis Access among the Elderly in the Era of Fistula First

“…However, this survival advantage was not observed in octogenarians and nonagenarians (19). Results from a smaller cohort of the Dialysis Morbidity and Mortality Study demonstrated no survival benefit of fistula over graft in those aged $65 years (17). Similarly, in a decision analysis, men with diabetes had a modest survival benefit at younger ages with a fistula first strategy, but this benefit progressively diminished with increasing age.…”

“…(2) This statement is based on two references: (1) a 2003 review article in which age was not a consideration and (2) a single institution study of 100 fistula and 109 graft patients with mean ages in the mid-to late 50s (15,16). More recently, the Dialysis Morbidity and Mortality Study demonstrated no patency advantage of fistula over graft in older adults (17). Likewise, a 2007 meta-analysis found that the 12-month primary and secondary patency rates of fistulas were lower in older adults (4).…”

Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis

“…Chan et al demonstrated that old age alone was not a predictor of lower patency and/or mortality rates in these patients, regardless of existing major comorbidities like diabetes. The authors concluded that the potential benefits of AVFs compared with AVGs and TCCs cannot be universally applied (27).…”

Interventional Nephrology

“…Data from the Dialysis Outcomes Quality Initiative Analysis have suggested a primary patency rate of 50% at 1 year for PTFE grafts (10), whereas other authors report primary patency rates as low as 23% at 1 year and 4% at 2 years, consistent with findings from the large DAC study reported in 2009 (2,40). Nevertheless, AV graft placement may be an ideal choice for certain populations, even preferable to the AV fistula in certain subsets of patients, as some studies have shown (41)(42)(43). Moreover, when failure of the AV fistula to mature is taken into consideration, AV grafts have very similar patency outcomes to AV fistulae and are usable much sooner (44).…”