Vascular access outcomes in the elderly hemodialysis population: A USRDS study

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.